COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX641 18088 
RC78  .B38  Rontgen  ray  diagnosi 


RECAP 


^CA* 


T* 


Columbia  WLnitozv&itp 
in  tfje  €itp  oi  Jleto  gorfc  ^^ 
Befool  of  Cental  anb  0val  gmrgerp 


Reference  Hibvavp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/rntgenraydiagnOObeck 


Rontgen  Ray 
Diagnosis  and  Therapy 


BY 


CARL   BECK,    M.  D. 


PROFESSOR    OF   SURGERY    IN    THE    NEW    YORK    POST-GRADUATE    MEDICAL 

SCHOOL   AND    HOSPITAL;    VISITING    SURGEON    TO    ST.    MARK'S 

HOSPITAL   AND   THE    GERMAN    POL1KLINIK 


WITH  322  ILLUSTRATIONS  IN   THE    TEXT 


NEW    YORK    AND    LONDON 

D.     APPLETON     AND     COMPANY 

1904 


Copyright,  1904,  by 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW   YORK,   U.   S.    A. 


O  light,  of  all  the  gifts  of  heaven, 
The  dearest,   best  !     From  light  all  beings  live — 
Each  fair  created  thing— the  very  plants 
Turn  with  a  joyful  transport  to  the  light. 

— Schiller. 


PREFACE 


Literature  upon  the  application  of  the  Rontgen  rays  has  be- 
come very  extensive.  Many  contributions  have  been  made  during 
the  last  few  years,  and  a  number  of  splendid  text-books,  like  those 
of  Morton,  Gocht,  Midler,  Donatb,  Williams.  Walsh,  and  Albers- 
Schoenberg,  were  written  on  this  fascinating  subject.  Still  none 
of  those  standard  works,  while  indispensable  for  the  Rontgen-ray 
worker,  treats  the  large  field  from  a  strictly  clinical  view-point. 
To  demonstrate  how  the  Rontgen  rays  can  best  be  utilized  in  med- 
ical and  surgical  practice  has  therefore  been  the  author's  aim. 
This  desire  underlies  the  continuous  allusion  to  clinical  points,  and 
especially  the  numerous  illustrations  of  therapeutic  means.  It  en- 
tailed representation  of  methods  (operative  steps,  application  of 
splints,  etc.),  which  at  first  glance  may  appear  foreign  to  a  treatise 
on  the  Rontgen  rays.  But  on  a  closer  study  it  will  be  evident  that 
these  can  be  understood  only  on  the  basis  of  an  exact  knowledge 
of  the  new  science. 

While  these  factors  are  the  predominating  feature  of  the  book, 
the  technical  points  are  not  neglected.  They  are  of  so  complicated 
a  nature  that  they  require  special  study,  as  do  the  microscope,  the 
laryngoscope,  the  ophthalmoscope,  asepsis,  etc.  The  employment 
of  the  apparatus  must  be  mastered  and  the  complicated  rationale 
of  the  various  changes  in  the  tubes  thoroughly  understood. 

In  the  General  Part  the  author  has  tried  to  furnish  a  guide  for 
practical  work,  emphasizing  the  essential  points  only.  Thus  he 
refrained  from  discussing  the  elementary  principles  of  electricity 
and  from  describing  the  large  number  of  apparatus  in  the  market 
because  they  are  thoroughly  advertised  and  explained  by  the  vari- 
ous firms  interested.  So  much  may  be  said,  however,  that  nearly 
all  of  them  are  useful,  as  long  as  they  are  in  good  order. 

As  this  book  is  written  for  physicians,  great  stress  has  been 
also  laid  on  topographic  anatomy.     None  except  the  physician  is 

v 


vi  THE    RONTGEN    RAYS 

deemed  as  competent  in  Rontgen  science.  It  is  only  the  knowl- 
edge of  anatomy  and  pathology  which  permits  correctly  placing 
the  part  to  he  examined  and  proper  interpretation  of  the  result. 
The  many  errors  which  were  and  are  still  attributed  to  the  rays  are 
not  only  due  to  technical  faults,  but,  in  the  large  majority  of  cases, 
to  insufficient  knowledge  of  normal  anatomy.  To  recognise  the 
atrophic  area  in  osteosarcoma,  or  to  differentiate  a  renal  calculus 
from  intestinal  contents  in  a  mediocre  skiagraph,  to  appreciate  a 
sesamoid  or  to  define  the  shadow  of  an  aneurysm,  requires  much 
scientific  knowledge  and  Rontgen  experience. 

It  must,  furthermore,  not  be  forgotten,  that  valuable  as  the 
Rontgen  method  is,  it  cannot  serve  as  a  substitute,  but  only  as  an 
important  adjunct  to  our  well-tested  clinical  methods. 

In  the  part  devoted  to  Rontgen  therapy  the  author  has  care- 
fully tried  to  keep  facts  and  conjectures  well  asunder,  appreciating 
the  limitations  of  this  new  field,  which  is  still  in  a  stage  of  devel- 
opment. 

The  skiagrams  are  exact  reproductions  of  photographic  prints. 
The  author  resisted  all  temptation  of  emphasizing  their  essential 
points  by  artistic  interference,  with  the  exception  of  two  illustra- 
tions in  which  the  important  points  were  lost  during  the  process  of 
reproduction.  None  of  the  representations  were  selected  for  their 
pictorial  excellence,  but  to  illustrate  the  points  of  the  text ;  there- 
fore the  author  often  had  to  sacrifice  some  of  his  beautiful  repro- 
ductions for  mediocre  ones  that  would  better  subserve  the  special 
purpose. 

It  affords  the  author  special  pleasure  to  thank  Professor  Ront- 
gen for  the  many  courtesies  of  which  he  has  been  the  recipient  at 
his  laboratory.  His  sincere  acknowledgments  are  also  due  to  Pro- 
fessors von  Bergmann,  Czerny,  Koenig,  Pfuhl.  Koehler,  Hilde- 
brand,  Koerte,  Hoffa,  Lesser,  Lassar,  Hochheimer,  Gocht,  Helbig. 
Surgeon-General  Stechow.  Dr.  Max  Levy,  and  to  Messrs.  Siemens 
and  Halske,  Max  Kohl,  and  the  Allgemeine  Elektricitaetsgesell- 
schaft.  Great  credit  is  due  to  Dr.  J.  R.  Broome  and  the  publish- 
ers, Messrs.  Applcton  &  Co..  for  the  typographic  and  pictorial  ex- 
cellence of  this  book. 

Carl  Beck. 

No.  37  East  Thirty-first  Street,  New  York, 


CONTENTS 


PAGE 

Introduction  .  1 


SECTION   I 

GENERAL   (TECHNICAL)   PART 

CHAPTER 

I. — The  Apparatus 7 

II. — Rontgen  Technique 24 

III. — Fluoroscopy 40 

IV. — Skiagraphy 45 

V.— Examination  of  the  Patient       .......  58 


SECTION   II 

REGIONARY    (CLINICAL)    PART 

VI.— Head 64 

VII.— Neck ?9 

VIII.— Chest 86 

IX. — Abdomen .111 

X. — Pelvis  and  Lower  Extremity 142 

XL — Shoulder  and  Upper  Extremity 178 

XII. — Malformations 240 

XIII. — Diseases  of  the  Bones  and  Joints 249 

XIV. — Neoplasms 284 

XV- — The  Utilization  of  the  Rontgen  Rays  in  Fractures    .        .  306 
XVI. — The  Operative  Treatment  of  "Deformed  Fractures  as  indi- 
cated by  the  Rontgen  Pays 310 

X VII.— The  Medico-legal  Aspect  of  the  Rontgen  Rays    .        .        .  339 

vii 


viii  CONTENTS 

SECTION   III 

EFFECTS  OF  THE  RONTGEN  RAYS 

PAGE 

XVIIL— Rontgen  Therapy .  360 

XIX. — Special  Indications 381 

XX. — Becquerel  Rays  and  Radium 431 

XXL — Pinsen  Method  and  Ultra-violet  Rays 436 

Bibliography 440 

Index 455 


LIST    OF    ILLUSTRATIONS 
GENERAL    PART 


CHAPTER  I 


THE    APPARATUS 


1.  Portable  Ron tgen-Ray  Apparatus     . 

2.  Field  Apparatus        .... 

3.  Field  Apparatus  ready  for  Use 

4.  Walter  Commutation  Arrangement  . 

5.  Static  Machine         .... 

6.  Simple  Wehnelt  Interrupter 

7.  Tube  provided  with  Osmo-Regeneration 

8.  Regulating  Tube       .... 

9.  Regulating  Tube  in  Use   . 


10.  Grunmach-Kny  Tube  provided  with  Water-Coolinj. 


Apparatus 


PAGE 

8 
9 
9 
11 
12 
13 
18 
20 
20 
21 


CHAPTER   II 

RONTGEN    TECHNIQUE,    PAGE  24 

11.  Beck's  Osteoscope    ..........  25 

12.  Osteoscope  in  Use     ..........  26 

13.  Lateral  Dislocation  of  Elbow  and  Old  Fracture  of  External  Condyle  27 

14.  Normal  Ankle-joint,  taken  with  a  Tube  of  Medium  Hardness  .  .  28 

15.  Fracture  of  Lower  End  of  Radius  followed  by  Displacement,  taken 

with  a  Soft  Tube       .........  29 

16.  Faint  indication  of  Bullet  in  the  Os  Magnum  and  Evidence  of  Small 

Fragments  in  the  Carpus  (Low  Vacuum  Tube)  ...  30 

17.  Bullet  Case,  illustrated  by  Figs.  16  and  18,  Lateral  Exposure  (Low 

Vacuum  Tube) 31 

18.  Bullet  Case,  illustrated  by  Figs.  16  and  17,  showing  Bullet  Distinct 

and  Bones  Translucent  (Tube  of  Medium  Hardness).         .         .  32 

19.  Plate  Diaphragm 34 

20.  Tubular  Diaphragm 34 

21.  Simple  Form  of  Lead  Diaphragm      .......  34 

22.  Simple  Compression  Diaphragm 35 

23.  Skiagraphing  Renal  Calculi  by  using  the  Compression  Diaphragm    .  35 

24.  Examining  the  Foot  by  the  Compression  Diaphragm        ...  36 


x  THE    RONTGEN    RAYS 

FIG.  PAOE 

25.  Author's  Movable  Diaphragm  .......       36 

26.  Textural  Details  shown  by  the  Aid  of  Author's  Diaphragm  in  Frac- 

ture of  Radius,  associated  with  Fracture  of  Styloid  Process  of 
Ulna 37 

27.  Skiagraphing  Hand  by  the  Aid  of  Author's  Diaphragm    .         .         .37 

28.  Skiagraphing  Head  by  the  Aid  of  the  Diaphragm     ....       38 

CHAPTER   III 

FLUOROSCOPY,  PAOE    40 

29.  Tracing  Apparatus  .  .         .  .         .         .         .         .         .         .41 

30.  Orthodiagraph^  Examination  .......       43 

31.  Hoffmann's  Measuring  Stand  ........       44 

CHAPTER   IV 

SKIAGRAPHY,    PAGE    45 

32.  Apparatus  of  Hildebrand         ........       51 

33.  Fracture  of  Femoral  Diaphysis,  showing  Angular  Deformity  (Ante- 

rior View)  ..........       52 

34.  Fracture  of  Femoral  Diaphysis,  showing  Overlapping  of  Fragments 

(Dorsal  View)    ..........       53 

35.  Fracture    of    the    Middle    of    the  Femur,  showing  Juxtaposition, 

Seven  Weeks  after  the  Injury,  in  a  Boy  of  Seven  Years     .  .       54 

36.  Localization  of  Bullet  in  the  Arm  by  AVire  Letters   ....       55 

CHAPTER   V 

EXAMINATION    OF   THE    PATIENT,    PAGE    58 

37.  Queen's  Examining  Table        ........       59 

CHAPTER   VI 

REGIONARY    (CLINICAL)    PART,    PAGE    64 


38.  Infantile  Skull  (Fracture  of  Skeleton) 

39.  Hydromeningocele   ......... 

40.  Nasofrontal  Hydromeningocele         ...... 

41.  Case  of  Hydromeningocele,  illustrated  by  Figs.  39  and  40,  One  Year 

after  Operation  ........ 

42.  Bullet  in  the  Skull  (Lateral  View) 

43.  Bullet  in  the  Skull  (Front  View) 

44.  Fracture  of  Inferior  Maxilla  Wired  ...... 

45.  Fracture  of  the  Inferior  Maxilla  Reduced   (Note  Outlines  of  the 

Upper  Trachea  and  the  Epiglottis)    .  .         .  . 

46.  Protruding  Filling  in  Tooth      ....... 

47.  Incisor,  situated  transversely  in  the   Superior   Maxilla  of  a  Girl  of 

Fifteen  Years    ......... 

48.  Transverse  Tooth  in  the  Mandible    ...... 


65 

66 
67 

69 
71 

72 
73 

74 
75 

76 

77 


LIST   OF   ILLUSTRATIONS 


XI 


CHAPTER    VII 

NECK,    PAGE    79 

FIG. 

49. ~A  Five-cent  Piece  in  the  (Esophagus 

50.  Goitre  containing  ('idea icons  Matter 

51.  Skiagraph  of  Calcareous  Deposits  in  Goitre, 

52.  Tuberculous  Glands  of  Neck 


-1  rated  by  Fit 


PAGE 
81 

83 

si 
85 


CHAPTER    VIII 

CHEST,    PAGE    86 

53.  Topographic  Relations  <>f  Intrathoracic  Viscera 

54.  Tuberculous  Foci  in  the  Lungs 

55.  Abscess  of  Lungs      ...... 

56.  Fifth,  Sixth,  Seventh  and  Eighth  Ribs,  Three  Weeks  after  Resection 

for  Old  Pyothorax  ........ 

57.  Hypertrophy  of  Left  Ventricle  after  Rheumatic  Endocarditis   . 

58.  Arteriosclerosis         ......... 

59.  Osseous  Degeneration  of  the  Saphenous  Vein  .... 

60.  Myelosarcoma  of  Thoracic  Wall       ...... 

61.  Perforating  Pyothorax  resembling  Solid  Tumor 

62.  Oesophageal  Stenosis  caused  by  Carcinoma      .... 

63.  Aortic  Aneurysm  projecting  into  the  Supraclavicular  Space 

64.  Aortic  Aneurysm   showing  Improvement  after  the  Administration 

of  Iodide  of  Potassium 

65.  Enormous  Aortic  Aneurysm,   causing  Atrophy  of  the  Clavicles  and 

the  Sternum      ..... 

66.  Aortic  Aneurysm  (see  Photograph,  Fig.  64) 

67.  Heart  and  Aortic  Aneurysm 

68.  Fracture  of  Scapula  and  Ribs   . 


87 
90 
91 

9:5 
95 

97 

98 

99 

100 

101 

102 

103 

104 
105 
108 
109 


CHAPTER   IX 

ABDOMEN,    PAGE    111 

69.  Subphrenic  Abscess  .........     112 

70.  Concretions  in  the  Hepatic  Ducts    .         .         .         .         .         .         .114 

71.  Various  Types  of  Biliary  Calculi       .         .         .         .         .         .  .115 

72.  Translucency  of  Gallstones  (compare  Figs.  71  and  73)       .         .         .     116 

73.  Biliary  Calculi,   illustrated  by  Figs.  71  and  72,  irradiated  through 

the  living  body  .         •         •         •         •         •         •         ■         .117 

74.  Position  for  Skiagraphing  Region  of  the  Gall-Bladder  by  the  Aid  of 

Author's  Diaphragm  ........     118 

75.  Faceted  Biliary  Calculi 120 

76.  Three  Biliary  Calculi .         -121 

77.  Solitary  Biliary  Calculus  .....-••     122 

78.  Biliary  Calculus 123 

79.  Numerous  Biliary  Calculi  in  Much  Distended  Gall-Bladder      .         .     124 

80.  Renal  Calculus 126 


THE  KONTGEN  KAYS 


FIG. 


81.  Resected  Halves  of  Vesical  Calculus,  illustrated  by  Figs.  82  and  S3 

82.  Vesical  Calculus,  (compare  Fig.  81)  ..... 

83.  Vesical  Calculus  (compare  Figs.  81  and  82)     .... 

84.  Vesical  Calculus  in  a  Man  of  Seventy  Years    .... 
8.5.  Spina  Bifida 

86.  Spina  Bifida,  showing  Hiatus 

87.  Spina  Bifida,  see  Fig.  88 

88.  Spina  Bifida,  illustrated  by  Fig.  87,  in  Antero-posterior  Projection 

89.  Rhaehitic  pelvis      .         .         .         . 

90.  Extrauterine  Mole,  containing  foetus,  removed  by  Laparotomy 

91.  Embryo  of  Three  Weeks 

92.  Embryo  of  Ten  Weeks 

93.  Fcetus  of  Four  Months-Abortus  caused  by  Syphilis  . 

94.  Fcetus  of  Five  Months 

CHAPTER  X 

PELVIS    AND    LOWER    EXTREMITY,  PAGE  142 

95.  Congenital  Dislocation  of  Both  Hips  in  a  Girl  of  Two  and  a  Half 

Years         .......... 

96.  Congenital  Dislocation  of  Left  Hip  in  a  Boy  of  Four  Years,  the 

Right  Hip  being  Normal  .  .         .  . 

97.  Congenital  Dislocation  of  Hip  in  a  Girl  of  Seventeen  Years,  the 

Empty  Acetabulum  showing  Well  Formed 

98.  Tuberculous  Hip-Joint  ........ 

99.  Fracture  of  Femoral  Neck 

100.  Fracture  of  Femur,  followed  by  Necrosis  .... 

101.  Sequestra  indicated  by  Skiagraph,  Fig.  100,  after  Removal    . 

102.  Popliteal  Aneurysm  showing  Phlebolith  ..... 

103.  Popliteal  Aneurysm  (compare  Skiagraph,  Fig.  102) 

104.  Normal  Knee-Joint         .         .         . 

105.  Patellar   Fragments    turned   after   Wiring     .... 

106.  Diastasis  of  Patellar  Fragments,  Twenty  Years  after  the  Injury 

107.  Transverse  Fracture  of  the  Patella  ...... 

108.  Normal  Sesamoid  of  the  Semitendinosus  Muscle     . 

109.  Osseous  Ankylosis  of  the  Knee 

110.  Oblique  Fracture  of  the  Tibia,  showing  Slight  Axial  Displacement 

111.  Fracture  of  Tibia,  showing  Anterior  Gaping    .... 

112.  Fracture  a  la  Bee  de  Flute  of  the  Tibia,  in  a  Boy  of  Nine  Years 

113.  Dressing  in  Pott's  Fracture  as  indicated  by  Skiagraphic  Anatomy 

114.  Pott's  Fracture 

11.5.  Fracture  of  the  Internal  Malleolus  reduced      .... 

116.  Fracture  of  Both  Malleoli,  associated  with  Backward  Displacement 

of  Foot  

117.  Case  Illustrated  by  Fig.  116  in  Oblique  Antero-Posterior  Projection 

118.  Fracture  of  the  Calcaneum     .  .         .         . 

119.  Foot  showing  Os  Trigonum  Tarsi   .... 


LIST   OF   ILLUSTRATIONS 


XI 11 


FIG.  PAGE 

120.  Fracture  of  Second  and  Third  Metatarsus,  followed   by  Lateral 

Displacement  .         .         .         .         .         .         .         .         .  1 74 

121.  Fracture  of  Second  Metatarsal  J  Jone        ......  175 

122.  Malunion  of  Fracture  of  Large  Toe,  Throe  Years  after  the  Injury     .  177 

CHAPTER   XI 


SHOULDER    AND    UPPER    EXTREMITY,    178 

123.  Deformed  Union  in  Fracture  of  the  Upper  End  of  the  Humerus 

(also  note  the  Normal  Relations  of  the  Thoracic  ( )rgans) 

124.  Impacted  Fracture  of  the  Surgical  Neck  of  the  Humerus  . 

125.  Deformed  Fracture  of  Surgical  Neck  of  Humerus   . 

126.  Anterior  View  of  Shoulder  (compare  Fig.  127) 

127.  Fracture  of  the  Anatomical  Neck  of  the  Humerus,  Posterior  View 

(compare  Fig.  12G)  ...... 

128.  Fibrous  Ankylosis  of  Shoulder         .         .         . 

129.  Fracture  of  the  Diaphysis  of   the  Humerus  in  a  Baby,   sustained 

during  Labor — (Rapid  Exposure)    .... 

130.  Wiring  of  Humeral  Head  to  the  Acromion  for  Old  Subcoracoid  Dis- 

location ......... 

131.  Subcoracoid  Dislocation  of  Humerus        .  .  .    . 

132.  Greenstick  Fracture  of  Humerus    ..... 

133.  Fracture  of  the  Diaphysis  of  the  Humerus,  Non-united  after  Nine 

Weeks     ......... 

134.  Refracture,  in  Case  illustrated  by  Fig.  133 

135.  Extreme  Displacement  causing  Diastasis  of  Fragments  and   Mus- 

cular Intervention   ......... 

136.  Well-united    Fracture  of  the   External  Condyle,  associated  with 

Slight  Downward  and  Inward  Displacement,  and  with  Out- 
ward Bending  of  the    Ulna    (the  Relations  of  the  Infantile 
Cartilages  being  Normal)         ..... 

137.  External  Condyle  Completely  Turned  after  being  Fractured 

138.  Supracondylar  Fracture  shortly  after  Reposition    . 

139.  Supracondylar  Fracture    displaced  Posteriorly   (Extension 

ture)         ......... 

140.  Oblique  Supracondylar  Fracture,    associated  with  Backward  Dis- 

placement in  a  Baby  of  Six  Months  .... 

141.  Supracondylar  Fracture 

142.  Old  Fracture  of  External  Condyle 

143.  Drop-Wrist,  due  to  Paralysis  of  the  Radial  Nerve,  caused  by 

ture  of  the  External  Condyle  (see  Fig.  142) 

144.  Backward  Dislocation  of  Elbow     ..... 

145.  Postero-Medial  Dislocation  of  Elbow       .... 

146.  Fracture  of  Coronoid  Process  of  Ulna  associated  with  Forward 

location  of  Radius   .         .         .         .  . 

147.  Fissure  of  the  Head  of  the  Radius   ..... 

148.  Fracture  of  Both  Bones  of  the  Forearm 


Frac- 


Frac- 


Dis- 


1S0 
181 
182 
183 

184 
185 

186 

187 
188 
189 

190 
191 

192 


195 
196 
197 

198 

199 
200 

201 

201 
202 
203 

204 
206 
210 


xiv  THE    RONTGEN"    RAYS 


149.  Fracture  in  the  Middle  of  the  Forearm  in  a  Boy  of  Three  Years   .     211 

150.  Displaced  Fracture  of  Radius  and  Ulna,  producing  Synostosis       .     212 

151.  Case  illustrated  by  Fig.  150,  after  Wiring 213 

152.  Fracture  of  Radial  Diaphysis  .  214 

153.  Fracture  of  Radial  Diaphysis  after  Alleged   Reduction  (compare 

Fig.  152) 215 

154.  Fracture  of  the  Ulnar  Diaphysis     .......     216 

155.  Fracture  of  Radius,  Upward  Bayonet-shaped  Displacement  218 

156.  Fracture  of  Lower  End  of  Radius,  showing  Upward  and  Inward 

Displacement  and  Outward  Bending  of  Ulna   ....     221 

157.  Oblique  Intra-Articular  Fracture  associated  with    Spiral-Shaped 

Fracture  of  Lower  End  of  Ulna 222 

158.  Outward  Displacement  in  Fracture  of  the  Lower  End  of  the  Radius 

in  a  Woman  of  Sixty  Years,  Four  Days  after  the  Injury   .         .     224 

159.  Thumb-Splint — Hand  slightly   Abducted — for  Fracture   followed 

by  Displacement      .         .         .         .         .         .         .         .         .     225 

160.  Upward  Displacement  in  Chondro-Epiphyseal  Separation       .         .     228 

161.  Fracture  of  Lower  End  of  Radius  associated  with  Fracture  of  Ulnar 

End,  in  a  Woman  of  Sixty-eight  Years 230 

162.  Fracture  of  Lower  End  of  Radius  associated  with  Dislocation  of 

Ulna 231 

163.  Case  illustrated  by  Fig.  164  after  Operation,  the  Trimmed  Radial 

Fragments  being  in  Apposition  after  Correction  of  the  Ulnar 
Portion  (taken  through  the  Plaster-of-Paris  Dressing)     .         .     232 

164.  Isolated  Fracture  of  Scaphoid  Bone         ......     234 

165.  Drainage-Tube  Splints  for  Metacarpal  Fracture       ....     235 

166.  Fracture  of  Fourth  Metacarpal  Bone,  causing  Sideward  Displace- 

ment (compare  Fig.  165)  .         .         .         .         .         .         .     236 

167.  Fracture  of  the  Second  Metacarpal  Bone         .....     237 

168.  Fracture  in  the  Middle  of  the  Fiftli  Metacarpal  Bone,  showing  En- 

sheathing  Callus      ..........     238 

169.  Old  Displaced  Fracture  of  the  Second  Metacarpal  Bone  .         .         .     239 


CHAPTER    XII 

MALFORMATIONS,  PAGE  240 

170.  Syndactylism  of  Third,  Fourth  and  Fifth  Fingers  in  a  Child  of 

Eight  Months  . 

171.  Metatarsal  Synostosis  in  a  Baby      ..... 

172.  Webbed  Fingers  and  Toes      .... 

173.  Congenital  Club-Hand,  and  Absence  of  Radius  and  Ulna 

174.  Congenital  Dislocation  of  the  Wrist         .... 

175.  Supernumerary  Toes      ....... 

176.  Congenital  Absence  of  Nasal  Bones  .... 

177.  Skiagraph  of  a  Case  of  Rudimentary  Ear,  illustrated  by  Fig.  178 

178.  Rudimentary  Ear  in  a  Child  of  Three  Months  (compare  Fig.  177) 


240 
241 
242 
243 
244 
245 
246 
246 
247 


LIST  OF   ILLUSTRATIONS  xv 

CHAPTER   XIII 

DISEASES  OF  THE  BONES  AND  JOINTS,  PAGE  2-19 

FIG.  PAGE 

179.  Osteomyelitic  Focus  of  Humerus    .......  250 

180.  Advanced  Stage  of  Osteomyelitis  of  Tibia      .....  251 

181.  Extensive  Osteomyelitis  at  the  Point  of  Perforation         .         .         .  252 

182.  Osteomyelitic  Focus  in  the  Tibia  (compare  Fig.  181)            .         .  253 

183.  Sequestrum  Exfoliating  from  the  Radius         .....  25  1 

184.  Osteoperiostitis  following  Phlegmon  of  Hand          ....  255 

185.  Synostosis  between  Radius  and  Ulna,  and  Exfoliating  Sequestrum  256 

186.  Sequestrum  in  the  Femur        ........  257 

187.  Necrotic    Radius    and   Eroded   Humerus,   Covered   by    Iodoform 

Gauze 258 

188.  Remnant  of  Radius,  showing  Beginning   Bone-Proliferation  after 

Removal  of  Necrotic  Area  (compare  Fig.  187)        .         .         .  259 

189.  Traumatic  Atrophy  of  Shoulder-Joint  and  Humerus,  followed  by 

Relaxation  of  Ligaments  (Subluxation) — Posterior  Exposure 

(compare  Fig.  190) 261 

190.  Same  as  Fig.  189  (Anterior  Exposure) 262 

191.  Enlargement  of  Internal  Condyle,  causing  Valgus  Position  of  Knee, 

in  Tuberculosis  (compare  Fig.  192)  ......  264 

192.  Tuberculous  Knee-Joint  after  Osteotomy  (compare  Fig.  191)  .         .  265 

193.  Tuberculous  Knee,  showing  Erosion  of  Cartilages    ....  266 

194.  Enlargement  of  Both  Internal  Condyles  in  a  Boy  of  Fourteen  Years, 

four  Months  after  his  Tuberculous  Gonitis  was  cured  by  the 

Injection  of  Iodoform-Glycerine      ......  267 

195.  Photograph  of  Case  of  Tuberculous  Knee  illustrated  by  Fig.  196      .  268 

196.  Tuberculous  Foci  in  and  around  the  Knee-Joint  (see  Fig.  195)  .         .  269 

197.  Synostosis  between  Patella  and   Femur,   before  Operation  .         .  270 

198.  Exophthalmus  caused  by  Tuberculous  Destruction  of  Skull    .         .  270 

199.  Skiagraph  of  Case  illustrated  by  Fig.  198 271 

200.  Swelling  of  Hand  in  Tenontitis  and  Tenontothecitis  Prolifera  Cal- 

carea  (see  Fig.  201) 272 

201.  Tenontitis  and  Tenotothecitis  Prolifera  Calcarea  (see  Fig.  200)         .  272 

202.  Rhachitic  Deformity  of  Lower  Extremities   .....  274 

203.  Rhachitic  Tibia 274 

204.  Arthritis .276 

205.  Fracture  of  the  Coronoid  Process  of  the  Ulna,  followed  by  Arthritis  .  277 

206.  Luetic  Destruction  of  Frontal  Bone       ......  278 

207.  Destruction  of  Frontal  Bone  (compare  Figs.  206  and  208         .         .  278 

208.  Skiagraph  of   Necrotic   Fragments  after  Removal  (see  Figs.  206 

and  207)  .         . .278 

209.  Case  illustrated  by  Figs.  206,  207  and  208,  after  Operation    .         .  279 

210.  Destruction  of  Nose  and  Left  Frontal  Sinus  (compare  Fig.  211)     .  280 

211.  Luetic  Destruction  of  Nose  (compare  Fig.  210)         ....  281 

212.  Luetic  Osteoperiostitis  of  Tibia  (compare  with  Fig.  218,  illustrating 

Periosteal  Sarcoma)         ........  282 

213.  Syphilitic  Dactylitis  of  the  Phalangeal  Joint  of  the  Thumb    .         .  283 


xvi  THE    RONTGEN   RAYS 

CHAPTER  XIV 

NEOPLASMS,  PAGE  284 
FIG.  PAGE 

214.  Recurrent  Periosteal  Sarcoma  of  Humerus  (see  Fig.  215)         .         .  284 

215.  Periosteal  Sarcoma  of  Humerus  (see  Fig.  214)         ....  285 

216.  Osteosarcoma  of  Humerus 285 

217.  Periosteal  Sarcoma  of  the  Tibia  radiating   into   the  Surrounding 

Tissues  (compare  with  Fig.  212,  illustrating  Lues)  .         .         .  286 

218.  Osteosarcoma  of  Right  Arm  (see  Fig.  219) 287 

219.  Skiagraph  of  Arm  illustrated  by  Fig.  218 288 

220.  Myelogenous  Osteosarcoma  of  Lower  End  of   Radius   (compare 

Fig.    221) 288 

221.  Myelogenous  Osteosarcoma  of  Lower  End  of    Radius    (compare 

Fig.  220)  . 

222.  Osteosarcoma  of  Radius 


223.  Osteosarcoma  of  Radius 

224.  Osteosarcoma  of  Femur 

225.  Large  Lipoma  of  Thigh  . 


289 
290 
290 
291 
292 


226.  Sarcoma  of  Superior  Maxilla  extending  to  the  Os  Frontis      .         .  293 

227.  Osteoma  of  Humerus     .........  294 

228.  Multiple  Exostoses  (Humerus,  Scapula  and  Ribs)    ....  295 

229.  Osteoma  of  Finger  (see  Fig.  230) 295 

230.  Chondroma  of  First  Phalanx  of  Middle  Finger  (see  Fig.  229)   .         .  296 

231.  Fibroma  of  Fourth  Finger 296 

232.  Foot  in  Acromegaly 297 

233.  Osseous  Cyst  of  Tibia 300 

CHAPTER  XV 

UTILIZATION  OF  THE  RONTGEN  RAYS  IN  FRACTURES,  PAGE  306 


CHAPTER  XVI 

THE  OPERATIVE  TREATMENT  OF  DEFORMED  FRACTURE  AS  INDICATED  BY 
THE  RONTGEN  RAYS,  PAGE  310 


234.  Fracture   of   Tibia   and    Fibula,    taken    through   Plaster-of-Paris 

Dressing . 

235.  Fracture  of  the  Surgical  Neck  of  the  Humerus — Juxtaposition 

236.  Fracture  of  Tibia  Wired,  and  Double  Fracture  of  Fibula  in  Mai 

union        .......... 

237.  Wire  Left  in  situ  after  Suturing  the  Radius — Relations  analogous 

to  Fig.  236 

238.  Diastasis   of  Fragments  causing  Pressure  upon  the  Musculospiral 

Nerve      .......... 

239.  Fracture   of   Radial   Head,   showing   Considerable   Outward   Dis 

placement  (compare  Figs.  240  and  241)  .... 

240.  Fractured  Radial  Head  illustrated  by  Fig.  182  after  a  Futile  Effort 

at  Reduction  (compare  Figs.  239  and  241) 


311 
312 

314 

315 

316 

319 

320 


LIST    OF    ILLUSTRATION'S  xvii 

FIG.  PAGE 

241.  Radial  Head  Reduced,  taken  through  the  Plaster-of-Paris  Dressing 

(compare  Figs.  239  and  240)  .......  321 

242.  Diastasis  of  Fragments  in  Fracture  at  the  Ulna  (compare  Fig.  226),  322 

243.  Ideal  Union  after  Fracture  of  the  Olecranon,  Three  Weeks  alter  the 

Injury  (compare  Fig.  212)       .          .          .          .          .          .          .  .'523 

244.  Oblique  Fracture  of  Olecranon  Wired    ......  324 

245.  Fracture  of  Diaphysis  of  Humerus  associated  with  Separation  of 

Fragment 326 

24G.  Juxtaposition  in  Fracture  of  Femur         ......  328 

217.  Transverse  Fracture  of  Femur  Non-united.     Angular  Deformity 

corrected  Eleven  Weeks  after  the  Injury        ....  320 

248.  Fracture  of  Lower  End  of  Radius  followed  by  Upward  and  Side- 

ward Displacement           ........  330 

249.  Wrist  after  Removal  of  Displaced  Fragment  (compare  Fig.  248)  331 

250.  Fracture  of  Upper  End  of  Ulna  associated  with  Sideward  Disloca- 

tion of  Radius  (compare  Figs.  251  and  252  )    .         .         .         .  332 

251.  Elbow  after  an  Effort  to  reduce  the  Fragment  (compare  Figs.  250 

252) 333 

252.  Case  illustrated  by  Fig.  250,  after  Bloody  Reposition  (compare  I rig. 

251) * 334 

253.  Fragment  of  Calcaneum  adjusted  to  the  Tibia  by  a  Screw  after 

Pirogoff  s  Amputation     ........  335 

254.  Compound  Fracture  of  Ulna  ........  336 

255.  Multiple  Fracture  of  the  Lower  End  of  the  Radius  ....  336 

256.  Tibia  Fractured  by  Gun-shot 337 


CHAPTER  XVII 

THE    MEDICO-LEGAL    ASPECTS    OF   THE    RONTGEN    RAYS,    PAGE    339 

257.  Needle  in  the  Foot  of  a  Dwarf 342 

258.  Fracture  of  Radial   Diaphysis,  overlooked  first  by  Fluoroscopic 

Examination  as  well  as  in  a  Mediocre  Skiagraph      .         .         .     348 

259.  Fracture  of  Tibia — Lateral  Exposure    ......     350 

260.  Fracture  a  la  Bee  de  Flute  of  the  Middle  of  the  Tibia — (compare 

Fig.  259)  Anterior  Exposure .353 

261.  Shattered  Elbow .         .         .355 

SECTION  III.— EFFECTS   OF   THE   KONTGEN  EAYS 
CHAPTER  XVIII 

RONTGEN  THERAPY,  PAGE  360 

262.  Rontgen  Light  Burn  of  the  Second  Degree  .....     368 

263.  Rontgen  Hand 370 

264.  Telangiectasis  Two  Years  after  Rontgen  Light  Dermatitis     .         .     374 

B 


xviii  THE    KOXTGEN    KAYS 

CHAPTER  XIX 

SPECIAL    INDICATIONS,    PAGE  381 

fiO-  PAGE 

265.  Sykosis  (compare  Fig.  248) 382 

266.  Case  of  Sykosis  illustrated  by  Fig.  265  after  One  Exposure    .         .  383 

267.  Lupus  Simplex  (compare  Fig.  268) 38S 

268.  Case  of  Lupus  Simplex  illustrated  by  Fig.  267,  Cured  by  Irradiation  389 

269.  Lupus  Erythematodes  (compare  Fig.  270)     .....  390 

270.  Case  of  Lupus  Erythematodes,  illustrated  by  Fig.  269,  cured    by 

Irradiation       ..........  391 

271.  Carcinomatous  Area  not  affected  by  the  Rays  (compare  Fig.  272)     .  393 

272.  Carcinomatous  Area  after  Irradiation,  showing  Colloid  Degenera- 

tion (compare  Fig.  271)            .         .         .         .         .         .         .  394 

273.  Epithelioma  of  Lower  Lip  and  Canthus  (compare  Fig.  274)       .         .  397 

274.  Case  of  Epithelioma  illustrated  by  Fig.  273,  Cured  by  Irradiation  .  398 

275.  Epithelioma  of  Lower  Lip  (compare  Fig.  276)     .....  399 

276.  Carcinomatous    Tumor    of    Inferior     Maxilla    and    Submaxillary 

Tissues  (compare  Fig  275.) 399 

277.  Carcinomatous    Growth  in  the  Inguinal  Region  Two  Years  after 

Removal  of  Mamma? 400 

278.  Carcinoma  Mammae  after  Operation  for  Ninth  Recurrence  (compare 

Fig.  279) 401 

279.  Case  of  Carcinoma  Mamma?  after  First  Operation  (compare  Fig.  27S)  402 

280.  Recurrent  Carcinoma  Mamma?  (compare  Fig  281.)          .          .          .  403 

281.  Case  illustrated  by  Fig.  280,  Recovering 403 

282.  Fibrocarcinoma  Mamma?  a  Year  after  its  Onset     ....  404 

283.  Recurrence  of  Carcinoma  Mamma?  .......  405 

284.  Infraclavicular  Carcinoma  in  a  Woman  of  Seventy  Years        .          .  406 

285.  Carcinoma  of  Skull 407 

286.  Carcinoma  Developing  from  an  Old  Sebaceous  Cyst          .          .         .  407 

287.  Epithelioma  of  Lower  Lip 407 

288.  Carcinoma  of  Vaginal  Introitus  in  a  Woman  of  Sixty-seven  Years  .  408 

289.  Melanosarcoma 408 

290.  Specimen  of  Case  of  Melanosarcoma  illustrated  by  Fig.  289     .          .  409 

291.  Melanosarcoma  (compare  Figs.  289  and  290) 409 

292.  Appearance  after  Seventh  Irradiation  (compare  Figs.  289,  290,  and 

291) 410 

293.  Osteosarcoma  of  Orbit  showing  Necrotic  Rontgen-Ray  Burn  .         .  410 

294.  Osteosarcoma  illustrated   by  Fig.  293 — One  Year   later  (compare 

Fig.  293 411 

295.  Skiagraph  of  Case  illustrated  by  Figs.  293  and  294  .         .         .         .412 

296.  Glioma 413 

297.  Osteosarcoma  of  Skull  (compare  Figs.  299  and  300)  .         .         .414 

298.  Round  Cell  Sarcoma 415 

299.  Case  illustrated  by  Fig.  297  Two  Years  after  Extirpation  .         .  416 

300.  Recurrent  Sarcoma  of  Skull  treated  by  Irradiation  (compare  Figs. 

297  and  299) 417 

301.  Sarcomatous  Tissue  after  Irradiation      ......  418 


LIST   OF    ILLUSTRATIONS  xix 

vm.  PAGE 

302.  Sarcomatous  Tissue  after  Irradiation  (Epithelium  wanting)   .         .  i  1  s 

303.  Sarcomatous  Tissue,  Deep  Stratum,  after  Irradiation     .         .         .  419 

304.  Osteosarcoma  originating  from  Superior  Maxilla  (compare  Fig.  305)  420 

305.  Case  of  Osteosarcoma  of  Superior  .Maxilla  illustrated  by  Fig.  304, 

after  Removal         .         .         .         .         .         .         .         •         .420 

30G.  Osteosarcoma  of  Superior  Maxilla  .......  421 

307.  Osteosarcoma  originating  from  Inferior  Maxilla     ....  421 

308.  Sarcoma  originating  from  the  Periosteum  of  the  Sternum  and  the 

Second  Rib      ..........  421 

309.  Fibrosarcoma  Mammae  in  a  Woman  of  Twenty-three  Years  421 

310.  Sarcoma  of  Groin  in  a  Man  of  Forty  Years    .....  422 

311.  Periosteal  Sarcoma  of  External  Condyle 122 

312.  Sarcoma  of  Leg  showing  Gangrene  in  its  Centre     .         .         .  423 

313.  Proliferating  Sarcoma  of  Leg           .......  423 

314.  Periosteal   Sarcoma        .........  424 

315.  Osteosarcoma  of  Frontal  Bone  and  Orbit       .....  424 

316.  Tuberculosis  of  Thumb 428 

317.  Adenoma  of  Tongue 42S 

318.  Malignant  Lymphoma 429 

319.  Noma  after  Scarlet  Fever 430 

CHAPTER   XX 

BECQUEREL  KAYS  AND  RADIUM,  PAGE  431 

320.  Skiagraph  of  a  key  by  Bromide  of  Radium 433 

321.  Skiagraph  of  Hand  by  Bromide  of  Radium 434 

CHAPTER  XXI 

FINSEN    METHOD    AND    ULTRA-VIOLET   RAYS,    PAGE   436 

322.  Irradiation  by  Finsen  Light 439 


INTRODUCTION 


THE  NATURE   AND   THE   PROPERTIES    OF    THE 
ROXTGEN  RAYS 

The  discovery  of  the  wonderful  rays  was  not  a  mere  lucky 
hit,  but  represents  the  result  of  indefatigable  scientific  research. 
That  electric  induction  obeys  the  same  laws  as  those  governing 
the  diffusion  of  light  waves,  and  that  the  speed  of  transmission 
of  the  electric  waves  is  equal  to  that  of  the  light  waves,  has  been 
proved  before  Rontgen.  In  fact,  the  phenomena  of  electric  dis- 
charge in  closed  tubes  of  various  degrees  of  exhaustion  and  filled 
with  different  gases,  had  been  a  favourite  subject  of  experiment  for 
a  large  number  of  physicists.  That  there  was  a  marked  differ- 
ence between  the  phenomena  of  light  at  the  two  electric  poles  was 
known,  as  well  as  the  fact  that  as  soon  as  the  vacuum  of  a  tube  is 
increased  to  a  high  degree  the  light  of  the  positive  pole  decreases, 
while  that  of  the  negative  pervades  the  vacuum  more  and  more. 

The  light  emanating  from  the  negative  pole  is  called  the 
cathode  ray.  Lenard  and  Hittorf  found  that  such  rays  have  power 
of  creating  fluorescence,  heat,  etc.,  and  that  they  can  be  deflected 
by  a  magnet.  The  vacuum-tube  commonly  used  is  generally  called 
the  Crookes  tube,  after  Sir  William  Crookes,  who  described  and 
modified  the  tube  by  bringing  the  vacuum  up  to  0.000001  mm. 
The  credit  for  having  originally  devised  it,  however,  is  due  to 
Geissler,  the  ingenious  mechanician  of  Bonn,  a  German  university 
town. 

As  soon  as  an  electric  current  of  high  intensity  goes  through 
the  conducting  wires  fused  into  the  end  of  a  tube  of  this  kind  the 
negative  electrode  or  cathode,  becomes  surrounded  by  a  faint  dark- 
blue  light,  while  the  positive  electrode,  the  anode,  sends  a  peach- 
coloured  light  through  the  tube  as  far  as  the  light  of  the  cathode. 
As  the  air  is  gradually  rarefied  the  positive  light  almost  disap- 
2  1 


2  THE    RONTGEN    EAYS 

pears,  while  the  negative  cathode  light  extends  more  and  more, 
and  finally  fills  the  whole  tube. 

Hertz,  of  Bonn,  found  in  1892  that  these  rays  penetrated  gold- 
leaf  and  other  sheets  of  metal.  His  experiments  were  continued  by 
Lenarcl,  his  assistant,  but  it  was  reserved  for  Rontgen  to  lift  the 
veil.  In  the  course  of  a  study  of  these  properties  he  discovered  an 
astonishing  phenomenon.  He  surrounded  an  exhausted  tube  with 
black  pasteboard,  thus  making  it  impermeable  by  light.  As  soon  as 
an  electric  current  went  through  the  tube  now,  the  latter  threw 
light  upon  a  screen  painted  with  a  light  colour  (barium  platino- 
cyanide). 

Now  it  became  evident  at  once  that  there  was  a  radiant  power 
which,  although  not  perceptible  to  the  eye,  permeated  the  paste- 
board. This  force,  heretofore  unknown,  also  showed  a  marked 
effect  on  the  screen.  After  finding  that  the  effect  of  these  invis- 
ible rays  upon  the  screen  was  constant,  Rontgen  tried  photo- 
graphic experiments  also.  He  then  discovered  that  under  the  in- 
fluence of  these  rays  his  hand,  resting  on  the  cover  of  a  wooden 
box,  gave  a  sharp  silhouette  on  a  drying  plate  below,  although  the 
cover  was  not  removed.  He  also  found  that  paper,  wood,  and 
even  thin  disks  of  metal  were  permeable  by  the  rays,  while  thick 
disks  of  metal,  bones,  etc.,  produced  silhouettes.  The  greater  the 
density  was,  which  to  a  great  extent  is  proportional  to  the  atomic 
weight,  the  less  the  translucency  became.  Rontgen  modestly  sug- 
gested naming  the  new  rays  "  X-rays/'  until  their  nature  should 
be  discovered.  It  is  generally  assumed  that  the  Rontgen  rays  are 
transverse  vibrations  of  the  ether,  there  being  a  series  of  isolated 
impulses  in  contradistinction  to  the  regular  wave  phenomenon  of 
ordinary  light. 

Scarcely  eight  years  have  elapsed  since  the  discovery  of  the 
Rontgen  rays.  While  we  still  may  speak  of  an  experimental  stage, 
the  results  obtained  are  marvellous.  Many  doctrines  formerly 
regarded  as  incontrovertible  have  since  been  completely  changed. 
It  is  significant  that  the  progress  of  our  pathological  knowledge 
has  altered  many  clinical  pictures,  and  in  extending  our  diagnostic 
horizon  has  simplified  our  therapy.  In  the  better  understanding 
of  numerous  pathological  processes  a  revolutionary  change  has 
taken  place,  and  it  is  gratifying  to  note  that  with  the  clearing  up 
of  the  anatomical  conditions  by  the  miraculous  rays,  the  ratio 
between  therapy  and  pathological  knowledge  has  been  altered  by 


[NTRODUCTION  3 

a  great  increase  in  the  latter.  Ii  is  an  old  dictum  thai  the  largesl 
number  of  medicaments  is  recommended  for  those  ailments  which 
are  least  understood.  The  clearer  the  understanding  becomes  of 
the  genesis  and  the  anatomical  relations  of  a  pathological  condi- 
tion, the  more  the  manifold  therapeutic  methods  shrink  into  a  few- 
simple  principles,  which,  in  Fad.  could  he  written  on  a  finger-nail, 
like  the  classic  prescriptions  of  our  greal  medical  ancestor. 

Indeed,  the  proofs  of  the  great  usefulness  of  the  rays  in  sur- 
gery as  well  as  in  medicine  are  now  overwhelming.  The  recogni- 
tion of  foreign  bodies  in  the  remotest  corner  of  the  living  organ- 
ism has  become  a  matter  of  ease.  Fractures  and  dislocations  are 
shown  as  they  really  are  in  life.  Accuracy  takes  the  place  of 
ignorance  and  doubt,  and  painful  manipulations  cease  to  be  nec- 
essary for  diagnostic  purposes.  Even  the  most  skilful  experts 
in  fractures  are  unable  to  deny  thai  there  is  a  large  number  of 
bone-injuries,  the  character  of  which  could  formerly  not  be  recog- 
nised on  account  of  the  swelling  of  the  area  involved  or  of  the 
obscurity  of  the  symptoms.  The  number  of  cases  of  fracture  for- 
merly mistaken  for  contusion  or  distortion  was  enormous.  It 
is  in  such  a  case  that  a  simple  glance  with  the  fluoroscope  fur- 
nishes the  most  precise  evidence.  Whether  there  is  comminution 
or  impaction,  or  the  intervention  of  muscular  tissue,  or  intra-ar- 
ticular  fracture,  or  association  with  a  dislocation,  can  be  at  once 
clearly  determined.  If  the  picture  is  fixed  on  a  photographic 
plate  the  nature  of  the  injury  can  be  studied  at  leisure,  and  the 
proper  line  of  treatment  easily  decided  upon,  without  subjecting 
the  patient  to  any  tentative  manipulations.  After  a  dressing  is 
applied  the  skiagram  shows  whether  the  fragments  are  in  proper 
position.  The  execution  of  all  therapeutic  measures  can  be  veri- 
fied through  it,  the  course  of  treatment  by  the  skiagram,  the  dress- 
ing itself,  even  if  consisting  of  plaster  of  Paris,  offering  no  obsta- 
cle to  the  rays.  Thus  the  therapy  is  simplified  and  perfected,  the 
Rontgen  guide  showing  the  true  nature  of  the  conditions.  Now 
it  is  easily  determined  whether  an  ankylosis  is  fibrous  or  osseous; 
and,  consequently,  the  question  whether  the  breaking  up  of  adhe- 
sions or  resection  is  indicated  is  settled  at  once. 

It  is  needless  to  call  attention  to  the  frequent  importance  of 
a  skiagraphic  proof  in  court,  for  the  protection  of  the  surgeon  as 
well  as  of  the  patient. 

Especially  in  the  better  understanding  of  fractures  a  revolu- 


4  THE    RONTGEN    RAYS 

tionary  metamorphosis  has  taken  place.  It  was  not  an  agreeable 
feature  of  the  rays  that  they  soon  told  most  impolitely  how  often 
we  have  erred  in  the  true  recognition  of  the  various  fracture 
types.  For  those  surgeons,  however,  who  soon  appreciated  the 
immense  value  of  one  of  the  greatest  discoveries  of  all  times,  the 
increasing  capacity  of  recognising  their  own  errors  has  become  a 
continuous  source  of  scientific  satisfaction,  which  found  its  cul- 
mination in  the  blameless  results  of  their  cases.  "  Our  sight,"  says 
Addison,  "  is  the  most  perfect  of  our  senses,"  and  the  small  flock 
of  Thomases  who  imagine  that  by  virtue  of  their  own  especially 
developed  palpatory  talent  they  can  just  as  well  judge  any  frac- 
ture without  the  aid  of  the  Rontgen  rays  will  not  escape,  in  the 
course  of  time,  the  natural  shrinking  of  their  cell-walls.  They 
will  share  the  fate  of  antiasepticists  and  of  obstructionists  in 
general. 

When  the  microscope  was  invented  great  authorities  used  to 
speak  with  unutterable  contempt  of  it,  and  others  denounced  an- 
aesthesia as  an  unscriptural  procedure.  When  Helmholtz  invented 
the  ophthalmoscope,  some  of  those  who  hear  the  grass  grow  pro- 
nounced it  to  be  a  nice  little  thing,  which  might  be  useful  for  bad 
eyesight,  while  they  themselves,  thank  God,  enjoyed  good  eye- 
sight, and  had  no  need  of  this  new  acquisition  for  their  diagnostic 
armamentarium.  When  the  immortal  genius  of  the  Italian  physi- 
cian, Galvani,  practically  discovered  electricity  by  his  experi- 
ments with  the  frog,  the  new  force  was  regarded  as  a  nice  play- 
thing— but  what  has  become  of  it  ?  Who  would,  in  the  face  of  the 
telegraph,  phonograph,  telephone,  the  trolley,  the  cystoscope,  etc., 
dare  to  say  now  that  electricity  is  only  a  little  plaything? 

Who  nowadays  would  dare  to  make  a  diagnosis  of  renal  dis- 
ease without  the  microscope?  Is  it  still  an  instrument  merely 
for  specialists?  No,  it  is  indispensable  for  the  general  practi- 
tioner, for  if  he  does  not  possess  such  an  instrument,  and  use  it 
intelligently,  he  will  be  left  behind.  The  microscope  alone  does 
not  make  the  diagnosis,  but  without  it  the  diagnosis  is  not  per- 
fect. It  is  just  the  same  with  the  Rontgen  rays.  The  general 
practitioner  must  use  them,  and  if  he  does  not  he  will  be  left 
behind.  Qui  non  proficit,  deficit!  This  may  be  unjust  and  cruel, 
but  it  is  a  fact,  and  facts  are  often  cruel. 

The  knowledge  of  the  various  diseases  of  bones  has  been  much 
augmented,  and  new  laws  of  differentiation  between  inflammatory, 


INTRODUCTION  5 

syphilitic,  tuberculous,  or  osteomyelitic  processes,  and  osteoma, 
osteosarcoma,  and  osseous  cysts  have  been  established.  The  pres- 
ence of  concretions  in  the  urinary  and  biliary  tracts  can  be  demon- 
strated. 

In  internal  medicine  the  rays  arc  also  more  and  more  appre- 
ciated to  their  full  value.  For  the  expert  they  prove  to  be  of 
incalculable  service  in  the  diagnosis  of  many  obscure  ailments. 

If  it  is  only  realized  that  most  of  the  diseases  of  the  thoracic 
organs  can  be  recognised  and  studied  by  the  rays,  as,  for  instance, 
pleurisy,  pyothorax,  pneumothorax,  lung  abscess,  tuberculous  foci 
and  cavities,  and  emphysema,  furthermore  that  the  relations  of  the 
heart  and  of  the  aorta,  aneurysms,  mediastinal  tumours,  and  ar- 
teriosclerosis can  be  thoroughly  studied,  the  immense  impor- 
tance of  the  rays  for  internal  medicine  becomes  at  once  apparent. 

Besides  their  diagnostic  properties  the  X-rays  exert  undeniable 
therapeutic  effects.  It  is  marvellous  that  not  only  certain  integu- 
mental  affections  are  completely  relieved,  but  that  even  malig- 
nant growths  are  strongly  influenced  and  some  of  them  cured. 
And  there  is  still  greater  hope  for  the  future ! 


S  E  0  T  I  O  N     I 

GENERAL    PART 


CHAPTEE    I 
TEE  APPARATUS 

As  alluded  to  before,  the  rays  are  projected  by  an  electric  dis- 
charge from  a  platinum  disk,  included  in  a  highly  exhausted  glass- 
tube,  which  is  opposite  the  negative  electrode,  or  cathode. 

To  produce  the  necessary  excitation  in  the  exhausted  tube 
(vacuum-tube  or  Eontgen  tube)  an  electric  current  is  required. 
But  the  electric  current  generally  used  in  an  electric-lighting  cir- 
cuit would  not  be  powerful  enough  to  span  the  space  of  air  left  in 
a  Eontgen  tube.  The  ordinary  electric-lighting  current,  as  it  is 
used  for  incandescent  lamps,  is  of  low  pressure  or  "  voltage " 
(generally  120  volts),  and  of  a  large  rate  of  flow  or  "amperes." 
The  current  for  the  excitation  of  a  Eontgen  tube  requires  a  high 
voltage  and  an  extremely  low  amperage.  Therefore  a  transforma- 
tion is  necessary.  In  other  words,  transformation  from  a  current 
of  high  intensity  and  low  tension  into  one  of  less  strength  and 
high  tension  must  be  made.  This  is  accomplished  by  means  of  a 
transformation  apparatus,  preferably  in  the  form  of  a  simple  in- 
duction coil  (Euhmkorff  coil).  Tesla  or  high-tension  induction 
coils  or  static  machines  are  also  in  use. 

The  essential  mechanisms  therefore  are  represented  by  the 
source  of  the  current  (the  exciting  apparatus),  the  transformer 
which  converts  the  electric  energy,  furnished  by  the  exciting  appa- 
ratus, into  a  form  suitable  to  the  Eontgen  tube,  and  the  tube,  in 
which  the  electric  energy  is  transformed  into  Eontgen  rays.  Some 
additional  apparatus,  like  stands,  fluoroscope,  and  photographic 
appliances,  the  utilization  of  which  will  be  considered  below,  is 
also  necessary. 

7 


8 


THE    RONTGEN    RAYS 


The  Source  of  the  Current. — Excitation  may  be  produced  by 
means  of  a  battery  or  of  a  direct  current,  the  latter,  of  course, 
being  far  superior  to  any  other,  since  there  is  neither  charging 
nor  supervising  necessary.  Not  the  least  of  its  advantages  is 
that  it  never  embarrasses  the  operator  by  proving  to  be  ineffi- 


Fig.  1.— Portable  Rontgen-Ray  Apparatus. 


cient.     Accordingly,  whenever  possible,  connection  with  the  110- 
or  120-volt  direct  current  should  be  made. 

If  the  direct  current  is  not  available,  a  so-called  Edison-La- 
lande  cell-battery  may  be  chosen.  For  use  when  travelling  storage 
batteries  may  be  preferred,  the  great  trouble,  however,  being  that 
if  they  become  exhausted  at  a  distance  from  a  city  they  cannot  be 


THE    APPARATUS 


9 


charged,  while  the  Edison-Lalande  cells  can   be  re-charged  any- 
where. 

Wherever  the  question  of  transportability  must  be  considered, 
portable  apparatus  must  be  used.     They  are  best  made  up  in  two 


Fig.  2. — Field  Apparatus. 

boxes,  so  that  a  man  can  carry  one  in  each  hand  (Fig.  1).  They 
are  made  equally  well  by  a  number  of  American  manufacturers. 
In  the  field,  accumulators  answer  the  purpose  best. 

They  are  placed  in  large,  closet-like  boxes.     Figs.  2  and  3  rep- 
resent a   field-apparatus   made  up   by  the   German   Government. 


Fig.  3. — Field  Apparatus  Ready  for  Use, 


10  THE    KONTGEN    EAYS 

They  resemble  the  ammunition  boxes  used  by  the  artillery,  and  are 
easily  moved  around. 

How  much  a  real  master  can  achieve  with  poor  means  is  shown 
by  Kuettner  and  Hiklebrand,  who  during  the  South  African  War 
made  splendid  skiagrams  in  the  battle-field.  There  was  only  small 
portable  apparatus  at  their  command,  they  had  only  poor  if  any 
assistance,  but  their  enthusiasm  overcame  all  difficulties. 

When  automobiles  containing  a  100-volt  storage  battery  are 
available,  insulated  wires  may  be  run  from  their  batteries  to  the 
sick-room,  where  they  are  connected  with  the  coil. 

The  Induction  Coil  (see  Eig.  9). — While  good  results  can  be 
obtained  with  small  induction  coils,  if  the  hand,  forearm,  foot,  or 
leg  are  concerned,  the  best  work  can  be  done  only  with  strong  coils. 
The  higher  the  vacuum  of  the  tubes,  the  more  penetrating  are  the 
rays  and  the  more  energy  is  needed  to  excite  them.  The  tubes  also 
become  impaired  pretty  soon,  if  used  in  connection  with  small 
coils.  It  is  furthermore  impossible  to  regulate  them  as  well  as 
large  coils.  For  the  examination  of  the  thicker  portions  of  the 
body,  such  as  the  pelvis,  spinal  column,  and  for  the  representa- 
tion of  concretions,  a  small  coil  is  useless.  It  is  certainly  tempt- 
ing to  buy  a  cheap  apparatus  if  the  firm  promises  that  equally 
good  results  can  be  obtained,  but  practice  shows  that  the  more 
expensive  apparatus  pays  best  by  giving  far  superior  results. 

This  fact  is,  of  course,  most  deplorable.  It  is  indeed  the 
main  obstacle  in  the  way  of  general  popularization  of  the  Rontgen- 
ray  method. 

It  is  agreed  among  the  best  authorities  in  this  field  that  a 
large  coil  of  a  spark-length  of  at  least  15  inches  answers  the  pur- 
pose sufficiently  well.  An  inductor  of  this  power,  with  a  110-volt 
direct  current,  should  afford  a  current  strength  of  from  1  to  2 
amperes.  It  consists  of  the  core,  the  primary  and  secondary  coil, 
the  terminals  of  the  secondary  coil,  a  condenser,  a  contact  breaker 
(electrolytic  interrupter,  vibrator,  or  air-brake  wheel),  and  a 
rheostat  (or  shunt  board). 

The  core  consists  of  a  cylindrical  bundle  of  soft-iron  wires 
which  are  firmly  bound  together.  To  secure  proper  insulation  the 
core  is  soaked  in  shellac  or  paraffin.  In  order  to  insure  quick 
demagnetization,  and  especially  to  prevent  heating  effects,  the 
wires  should  have  as  small  a  diameter  as  possible. 

Upon  the  insulated  core  the  primary  coil,  which  consists  of  two 


THE    APPARATUS 


11 


Layers  of  coarse  copper  wire,  is  wound.  After 
it  is  covered  with  a  tube  consisting  of  many 
layers  of  paraffined  paper  or  of  hard  rubber, 
the  secondary  coil  is  carefully  wound  upon  it. 
The  diameter  of  the  wire  for  the  secondary 
coil,  which  is  generally  wound  with  cotton  or 
silk  in  sections,  is  small.  Each  layer  must 
be  insulated  with  either  shellac  or  paraffin. 
Many  thousands  of  turns  are  required.  The 
terminals  of  the  wire  connect  with  two  bind- 
ing posts  containing  two  freely  sliding  rods. 

In  order  to  adapt  the  coil  to  sources  of 
different  potentials  the  primary  windings  are 
best  arranged  in  four  layers,  the  connection 
of  their  terminals  being  such  that  they  can 
he  employed  in  different  combinations  (see 
Walter  arrangement,  Fig.  4).  By  inserting 
plugs  (see  Fig.  4)  into  sockets  at  the  end 
of  the  core  any  connection  of  the  primary 
can  be  made.  The  resistance  of  the  vacuum- 
tube  is  greatly  influenced  by  this  adjustment. 
(Compare  description  of  Wehnelt  interrupter, 
p.  13.) 

In  the  interior  of  the  coil  a  condenser, 
made  of  a  number  of  sheets  of  tinfoil,  is 
placed.  This  makes  the  interruptions  of  the 
current  more  sudden,  thus  increasing  the 
electrostatic  capacity.  If  an  electrolytic  in- 
terrupter is  employed  no  condenser  is  re- 
quired. 

The  Static  Machine. — As  alluded  to,  the 
various  kinds  of  induction  coils  and  trans- 
formers represent  what  is  generally  known 
as  current  or  dynamic  electricity,  while  the 
static  machine  represents  electricity  at  rest. 
In  a  coil  the  induction  results  from  the  vari- 
ation of  currents,  which  flow  in  the  adjacent 
conductors.  But  in  a  static  machine  the  in- 
duction effects  are  created  by  the  opposite  and 
like  electricities  attracting  and  repelling  each 


JEi 


Pig.  4 — Waltek  Com- 
mutation Akrange- 

MENT. 


12 


THE    RONTGEN    RAYS 


other.  While  the  coil  needs  a  continuous  supply  of  current,  the 
static  machine  requires  only  an  initial  charge  of  electricity  which  is 
imparted  as  the  result  of  friction.    Thus  the  static  machine  repre- 


Fig.  5. — Static  Machine. 


sents  the  most  perfect  mechanical  means  for  creating  a  rapid  and 
continuous  succession  of  electric  discharges.  A  static  machine  best 
adapted  for  Rontgen-ray  work  is  one  in  which  a  high  rate  of 
motion  is  developed,  and  the  current  is  at  high  speed.  Of  course 
the  faster  the  apparatus  is  run  the  more  current  is  generated. 
Some  of  the  modern  static  machines  can  be  revolved  at  a  speed  of 
3,000  revolutions  a  minute. 

The  advantage  of  the  static  machine  is  that  it  requires  no  cells 
or  chemical  action.  For  good  Rontgen-ray  work  it  must  also  be 
connected  with  a  motor.  Under  favourable  circumstances  splendid 
work  can  be  clone  with  it,  but  it  condenses  moisture,  which  affects 
its  reliability.  The  temperature  also  influences  it.  The  fragility 
of  glass  gave  an  impetus  to  make  the  revolving  plates  of  a  mixture 
of  mica  and  shellac.  Thus  higher  speed  (2,000  revolutions  in  a 
minute)  can  be  obtained  with  safety,  but  the  practical  advantage  is 
questionable. 


THE    APPARATUS 


13 


In  running  a  static  machine  care  must  be  taken  to  separate  the 
sliding-pole  pieces  about  8  inches,  to  unscrew  the  large  halls  from 
the  pole  ends,  and  to  remove  the  Leyden  jars.  The  condenser 
must  then  be  screwed  on  and  the  square  platinum  disk  attached  to 
the  positive  pole  of  the  condenser.  The  length  of  the  spark  gap 
should  be  regulated  so  as  to  suil  the  vacuum;  it  must  be  long  if 
the  tube  has  a  low  vacuum,  and  be  short  if  it  has  a  high  one. 
The  case  should  often  be  ventilated  in  order  to  give  the  hygroscopic 
compounds  of  the  oxygen  and  nitrogen,  which  form  during  the 
operation,  a  chance  to  escape.  As  the  oil  at  the  bearings  easily 
becomes  sticky,  great  care  must  be  taken  to  keep  the  ends  always 
oiled.  If  the  machine  oil  has  become  thick  and  gummy,  the  bear- 
ing must  be  cleaned  with  thin  oil.  The  machine  must  never  be 
run  backward  or  with  wrong  poles.  Static  machines  require 
tubes  with  a  special  vacuum.  The  strong  tubes  described  below  are 
generally  not  to  be  used  in  connection  with  them.  The  best  static 
machines  are  made  in  the 
United  States. 

The  Interrupter. — With  the 
introduction  of  the  electro- 
lytic interrupter  by  Wehnelt 
the  technic  became  greatly 
simplified.  This  apparatus, 
invented  by  Spottiswoode  and 
modified  by  Wehnelt,  gives  a 
most  powerful  secondary  dis- 
charge, the  break  of  the  cir- 
cuit being  very  rapid. 

The  principle  of  its  con- 
struction is  that  a  small  plat- 
inum wire  is  passed  through 
a  porcelain  tube,  from  the 
sealed  end  of  which  its  tip 
projects  into  an  aqueous  solution  (10  per  cent)  of  sulphuric  acid 
(Fig.  6).  (The  regulation  of  the  extent  of  the  exposure  of  the 
platinum  surface  will  be  explained  further  below  in  connection 
with  the  handling  of  the  tubes — p.  32.) 

A.  lead  cathode  of  a  large  surface  is  immersed  into  the  same 
fluid,  through  which  the  current  is  sent.  The  efficiency  of  the  appa- 
ratus is  due  to  the  rapid  break  caused  by  the  sudden  generation  of 


Fig.   6. — Simple  Wehnelt  Interrupter. 


14  THE    KONTGEN    KAYS 

an  envelope  of  non-conducting  gas  (hydrogen  and  oxygen)  around 
the  platinum  tip.  As  the  expression  of  the  formation  of  detonat- 
ing gas  continuous  explosioisn  are  perceived.  The  number  of 
breaks  varies  with  the  amount  of  the  platinum  area  exposed,  and 
may  reach  10,000  per  minute.  The  large  amount  of  secondary 
energy  liberated  permits  of  very  short  exposures. 

The  fluid  is  contained  in  a  thick  glass  jar,  the  cover  of  which 
consists  of  hard  rubber.  It  carries  the  wires,  and  is  perforated 
in  order  to  permit  the  escape  of  the  gas. 

To  prevent  the  collection  of  gas  the  interrupter  should  not 
be  kept  in  a  closet.  Explosion  of  the  accumulated  gas  may  ignite 
the  closet.  The  terminus  must  be  connected  with  the  positive 
pole  of  the  supply  circuit,  while  the  lead  plate  carries  the  nega- 
tive wire.  Non-observance  of  this  rule  is  followed  by  the  burn- 
ing of  the  platinum  tip.  If  the  interrupter  stops  on  account 
of  a  gas-bubble  collecting  over  the  platinum  tip,  so  that  it  pre- 
vents contact  between  it  and  the  fluid,  the  current  must  be  reversed 
for  a  moment.     It  will  then  at  once  functionate  again. 

The  number  of  interruptions  is  somewhat  influenced  by  the 
amount  of  the  surface  of  platinum  exposed  to  the  electrolyte  as 
well  as  by  the  strength  of  the  current  which  passes  through  it. 
The  amount  of  the  projection  of  the  platinum  tip  is  regulated  by 
a  screw  attachment,  which  permits  of  adjusting  it  to  interrup- 
tions of  different  frequencies. 

The  interrupter  of  Caldwell  is  based  on  similar  principles. 
It  is  described  by  the  inventor  as  follows :  "  It  consists  of  a  jar 
containing  diluted  sulphuric  acid,  within  which  is  a  cup  of  insu- 
lating material  perforated  by  a  small  hole.  Lead  electrodes  are 
placed  in  the  outer  jar  and  in  the  insulating  cup. 

"When  the  primary  current  of  an  induction  coil  is  passed 
through  this  apparatus  there  is  comparatively  little  heating  of  the 
liquid  except  in  the  aperture  connecting  the  two  chambers,  where 
the  current  density  is  very  large  on  account  of  the  small  area  of 
the  aperture.  At  this  point,  therefore,  .sufficient  heat  is  developed 
to  vaporize  the  liquid  rapidly,  and  bubbles  of  steam  which  form 
break  the  connection  between  the  liquid  in  the  inner  jar  and  that 
in  the  outer  jar.  As  soon  as  the  current  is  broken  the  heating 
stops  and  the  two  portions  of  the  liquid  come  together  again,  com- 
pleting the  circuit.  The  frequency  of  tbe  interruptions  will  de- 
pend upon  the  strength  of  the  current,  the  size  of  the  aperture, 


THE    APPARATUS  L5 

the  resistance  of  the  electrolyte,  and  to  some  extenl  upon  the  induc- 
tance of  the  circuit.  [Ad  arrangement  for  varying  the  frequency 
of  interruption  by  adjusting  the  size  of  the  aperture  was  described 
by  Caldwell  in  the  New  York  Electrical  Review,  May  11,  1899.] 
In  this  arrangement  the  aperture  is  at  the  bottom  of  the  inner 
cup.  It  is  partly  closed  by  a  pointed  rod  of  non-conducting  ma- 
terial which  protrudes  through  it.  By  raising  or  lowering  the 
protruding  point  the  cross-section  of  the  annular  aperture  be- 
tween it  and  the  cup  may  be  varied,  and  thus  the  frequency  of 
interruptions  adjusted  through  a  wide  range.  Swinton  devised 
a  screw  adjustment  for  the  regulating  of  this  interrupter. 

"  This  apparatus  is  not  so  susceptible  to  change-  in  the  strength 
of  the  exciting  current,  or  to  changes  in  the  temperature  of  the 
liquid,  as  the  Wehnelt.  It  will  therefore  remain  in  operation  some- 
what longer,  and  admits  of  a  wider  range  of  adjustment  of  the 
exciting  current.  The  action  of  this  interrupter  is  quite  inde- 
pendent of  the  direction  of  the  current  through  it,  therefore  when 
employed  for  operating  induction  coils  on  the  alternating  cur- 
rent circuit  the  current  will  be  broken  at  each  alternation,  and 
the  secondary  discharges  will  alternate  in  direction.  Such  dis- 
charges are  not  suitable  for  operating  single-focus  tubes,  and  the 
interrupter  is  therefore  not  adapted  so  well  for  alternating  cur- 
rents as  the  Wehnelt  interrupter.  With  the  alternating  current  it 
is  possible  to  use  double-focus  tubes,  but  these  are  usually  unsat- 
isfactory except  for  therapeutic  purposes." 

In  order  to  avoid  overheating,  the  interrupter  may  be  provided 
with  a  water-cooling  jacket.  Running  water  from  a  local  supply 
system  may  be  passed  through  it.  If  only  moderately  used,  and  if 
the  jars  are  made  sufficiently  large,  this  precaution  can  be  dis- 
pensed with.  As  alluded  to  above,  no  condenser  is  required  with 
the  Wehnelt  interrupter. 

There  are  other  interrupters,  but  the  advantages  of  the  electro- 
lytic principle  are  so  apparent  that  the  others  are  very  little  used. 
Most  of  them  wear  rapidly  as  soon  as  currents  of  high  voltage  are 
used.  This  drawback,  which  is  especially  found  in  interrupters 
which  break  the  circuit  by  metallic  contact,  is  somewhat  overcome 
by  the  mercury  jet  interrupters,  whose  circuit  is  broken  by  a  jet 
of  mercury.  As  a  rule  the  mercury  is  covered  with  a  layer  of  alco- 
hol or  petroleum  in  order  to  prevent  sparking  when  the  rod 
emerges  from  the  mercury. 


16  THE    RONTGEN"    RAYS 

The  mercury  interrupter  of  Kohl  is  worked  by  a  battery,  the 
speed  being  controlled  by  a  rheostat.  The  regulation  takes  place 
by  a  lever  by  means  of  which  the  mercury  vessel  is  lowered  or 
raised. 

The  reliability  of  these  interrupters,  however,  is  still  ques- 
tionable. A  poor  interrupter  jeopards  the  whole  induction  coil, 
which  in  view  of  its  high  price  is  no  small  matter.  There  are  re- 
ports from  clinics,  in  which  the  simple  Wagner  interrupter  at- 
tached to  an  old  induction  coil  required  an  amperage  of  22  in 
order  to  produce  an  effective  light.  Such  apparatus  is  soon 
burned  out.  If  the  direct  current  is  not  available,  so  that  a  bat- 
tery must  be  used,  a  contact  breaker  must  be  adjusted,  which,  by 
quickly  making  and  breaking  the  current  passing  through  the  pri- 
mary coil,  controls  the  periodicity  of  the  vibration. 

Before  the  Wehnelt  interrupter  came  into  general  use  the  air- 
brake wheel  was  extensively  used  in  connection  with  the  direct  cur- 
rent. This  attachment  permits  of  great  rapidity  of  change  in  the 
electric  circuit,  thus  intensifying  the  electromotive  force  in  the 
secondary  coil.  It  consists  of  two  toothed  wheels,  the  projections 
of  which  are  brought  into  close  contact  with  two  flat  brushes, 
which  lead  the  current  in  and  out,  while  the  dentated  wheels  are 
rotated  at  a  high  speed  by  a  small  motor.  This  motor  runs  a  press- 
ure blower  at  the  same  time,  the  air-blast  from  which  is  directed 
to  a  two-forked  tube,  through  which  it  is  led  out  again  by  two  flat 
nozzles  placed  directly  above  the  brushes.  There  the  spark  is 
blown  out  by  the  air-blast  as  soon  as  it  forms  (Fig.  12). 

For  coils  of  small  size  simple  vibrating  interrupters  are  still 
employed,  which  operate  like  the  vibrating  hammer  of  the  electric 
bell. 

Rheostat  (Fig.  74). — The  amperage  is  reduced  by  an  adjust- 
able rheostat,  which  permits  of  perfect  control  over  the  current  pass- 
ing through  the  coil.  Instruments  of  this  kind  are  made  in  various 
forms,  their  principle  consisting  in  winding  thin  wires  in  many 
coils  around  an  ebonite  cylinder.  A  movable  key  is  constructed  in 
such  a  manner  that  it  can  be  made  to  press  on  any  part  of  the  wire. 
If  this  travelling  key  is  passed  along  the  bobbin,  the  current  goes 
through  as  much  of  the  resistance  wire  as  may  be  desired.  The 
greater  the  length  of  the  wire,  the  greater  the  resistance  will  be. 
In  order  to  reverse  the  current  a  double  ^oie-switch  is  attached 
to  the  coil.    This  opens  and  closes  the  circuit  (see  Figs.  8  and  9). 


THE    APPAEATUS  17 

To  prevent  a  powerful  current  from  passing  the  coil  by  accidenl  a 

protecting  fuse  is  included  in  the  circuit.  This  prophylactic 
medium  consists  of  a  small  piece  of  wire  which  by  virtue  of  its 
low  melting-point  becomes  fused  and  opens  the  circuit  as  soon  as 
the  current  is  too  powerful.  Fuses  should  always  be  on  hand, 
so  that  they  can  be  substituted  if  one  is  burned  out. 

The  Rbntgen  Tube. — The  Rontgen  tube  (see  Figs.  7,  8,  9, 
and  10)  represents  the  most  important  instrument  in  the  arma- 
mentarium. It  is  sometimes  possible  to  get  a  good  result  from  a 
poor  outfit,  if  there  is  only  a  good  tube;  but  the  best  outfit  will  be 
useless  if  a  poor  tube  is  connected  with  it.  The  principle  of  con- 
struction at  the  present  time  is  virtually  the  same  in  all  tubes. 
They  all  consist  of  a  glass  vessel,  usually  of  an  oblong  or  globular 
shape,  from  which  the  air  is  exhausted  and  into  which  the  ends  of 
electrodes  are  fused.  One  of  the  electrodes  ends  in  a  disk  of 
globular  concave  shape,  which  is  made  of  aluminum ;  this  elec- 
trode is  called  the  cathode.  The  other  ends  in  a  disk  of  flat  shape, 
which  is  of  platinum ;  this  is  called  the  anode.  The  anode  is  situ- 
ated opposite  the  cathode  at  an  angle  of  about  45  degrees.  Its 
shape  may  be  circular  as  well  as  square.  Almost  all  of  the  modern 
tubes  contain  a  second  anode,  which  is  connected  with  the  main 
anode. 

To  attain  a  suitable  vacuum  is  the  main  point  aimed  at.  The 
technical  difficulties  of  obtaining  the  desired  result  are  great,  con- 
sidering the  fact  that  the  intratubal  pressure  must  be  reduced 
to  about  two  millionths  of  atmospheric  pressure.  It  is  only  then 
that  the  remaining  gas  becomes  radiant.  This  rarefaction  of  the 
intratubal  air  is  brought  to  this  height  by  suitable  exhaust  pumps. 

The  cathode  rays  emanate  from  the  aluminum  disk.  Their 
focussing  point  is  situated  on  the  platinum  of  the  anticathode.  If 
this  point  is  situated  exteriorly  or  posteriorly  from  the  platinum 
instead  of  being  reached  directly  there  are  no  so-called  focus  rays, 
and  the  tube  is  practically  useless. 

Another  difficulty  encountered  in  the  use  of  the  tubes  is  due 
to  their  soon  becoming  inefficient  on  account  of  the  permanent 
change  of  pressure  that  occurs  within  them.  The  cathode  rays 
striking  the  platinum  disk  and  the  glass  walls  generate  a  certain 
amount  of  heat.  The  higher  the  temperature,  the  more  the  amount 
of  current  passing  through  is  increased,  and  the  more  the  vacuum 
is  lowered.  Unless  the  heat  is  dissipated  again  at  once  the  tube 
3 


18 


THE    RONTGEN    RAYS 


is  "unstable.  On  the  other  hand,  as  soon  as  the  tube  becomes 
colder  the  vacuum  increases.  Consequently  the  current  must  over- 
come a  greater  resistance,  a  lesser  amount  of  it  passes  through,  and 
therefore  a  lesser  amount  of  rays  is  generated. 

In  view  of  this  variation  of  pressure,  tubes  have  been  con- 
structed that  permit  lowering  and  raising  of  the  vacuum  within 
them  at  will.  Siemens  found  that  the  fluorescing  air  forms  dense 
bodies  with  the  vapours  of  phosphorus,  hydrate  of  potassium, 
iodine,  and  other  similar  substances,  thereby  diminishing  the  press- 
sure  within  the  tube.  On  the  other  hand,  if  the  walls  of  the  tube 
are  warmed,  the  stratum  of  air  that  condenses  on  the  glass  surface 
is  driven  away,  thereby  intensifying  the  pressure.  In  utilizing 
this  principle,  tubes  with  adjustable  vacuum  have  been  constructed 

which  are  provided 
with  an  adjuster, 
shortening  the  space 
between  the  spark 
rods. 

The  self-regulating 
tube  of  Queen  &  Co. 
(Philadelphia)  is  con- 
structed after  these 
principles,  the  small  auxiliary  tube  containing  hydrate  of  potas- 
sium, which  by  being  heated  gives  off  vapour,  and  absorbs  it  again 
when  cooling.  In  the  automatic  tube  of  Miiller  (Hamburg)  a 
plate  of  selenite  is  substituted  for  the  phosphorus  or  hydrate  of 
potassium,  because  this  mineral  does  not  re-absorb  the  gas  after 
it  is  given  off. 

The  principle  of  osmosis,  first  applied  in  France,  and  intro- 
duced into  practice  by  Gundelach,  utilizes  the  diffusion  of  hydro- 
gen for  regulation  (Fig.  7).  Into  the  cylindrical  wall  of  the  Gun- 
delach tube  a  small  palladium  wire  is  fused,  the  end  of  which  pro- 
trudes outside  to  the  extent  of  2  inches.  If  this  protruding  piece 
of  palladium  is  heated  by  an  alcohol  lamp  the  hydrogen  of  the 
flame  diffuses  into  the  interior  of  the  tube,  thus  augmenting  the 
intratubal  vacuum.  The  heating  process  must  be  kept  up  for  two 
seconds.  With  very  few  exceptions  the  skiagraphic  illustrations  of 
this  book  were  made  with  this  tube. 

The  Miiller,  Kny,  Voltohm,  Hirschmann,  and  Levy  tubes  are 
constructed  after  similar  principles,  and  are  also  useful.    All  their 


Fig.   7. — Gundei.ach  Tube  provided  with  Osmo- 
kegeneration. 


THE    APPAKATUS  19 

self-regulating  tubes  are  good  as  long  as  they  are  comparatively 
new.  After  being  used  for  a  while  the  usefulness  of  all  the  various 
types  becomes  impaired.     The  fact  must  not  be  losl  sight  of  that 

the  vacuum  of  the  tubes  is  increased  during  their  use,  which 
necessitates  a  proportional  increase  of  the  intensity  of  the  current. 
Therefore,  even  for  inductors  furnishing  a  very  long  spark,  tubes 
with  a  low  vacuum  should  be  chosen,  as  the  latter  increases  so 
much  during  use  that  at  last  the  full  power  of  the  apparatus  is 
required  for  producing  an  efficient  light.  Finally,  however,  the 
fluorescence  of  the  tube  ceases,  even  if  the  high  current  is  em- 
ployed. Then  the  vacuum  can  be  reduced  by  heating  the  tube 
with  an  alcohol  lamp,  while  a  weak  current  is  used,  until  the  fluor- 
escence becomes  distinct  again.  If  this  fails,  the  tube  should  be 
surrounded  evenly  and  tightly  by  gauze  compresses  slightly  mois- 
tened with  water. 

At  last,  of  course,  all  these  procedures  will  prove  to  be  with- 
out avail.  Some  tubes  regain  their  efficiency  simply  by  being  left 
untouched  for  a  few  weeks,  but  finally  they  all  become  useless  for 
diagnostic  purposes.  Then  the  resistance  of  the  tube  becomes  so 
great  that,  while  the  interior  hardly  shows  any  fluorescence,  most 
of  the  sparks  go  around  the  external  surface.  The  presence  of 
purple  or  red  light  points  to  a  leak,  which  naturally  renders  the 
tube  inefficient.    Leaky  tubes  may  be  repaired  by  sealing  the  defect. 

If  currents  of  very  high  intensity  are  used  the  platinum  disk 
of  almost  all  tubes  becomes  white  hot  after  a  short  time,  often 
after  a  few  seconds,  and  if  it  is  kept  glowing  a  little  longer  the 
platinum  melts.  To  obviate  this  most  embarrassing  occurrence, 
tubes  have  recently  been  constructed  in  such  a  manner  that  the 
metallic  parts  were  made  very  thick  and  resistant.  Such  tubes 
permit  of  a  current  of  maximum  intensity  for  about  one  minute; 
then  the  very  marked  outlines  of  the  picture  become  less  distinct; 
the  tube  filling  with  blue  light  at  the  same  time,  which  indicates 
that  it  is  overheated.  In  order  to  permit  of  longer  exposures 
Gundelach  has  recently  added  a  regulating  tube  (ventile  tube) 
(Fig.  8)  consisting  of  a  small  evacuated  glass-ball,  which  is  pro- 
vided with  anode  and  cathode  only.  By  prefixing  this  valve-like 
arrangement  to  the  tube,  the  formation  of  disturbing  alternating 
currents  inside  of  the  tube  is  prevented.  So  the  current  can  pass 
the  tube  in  one  direction  only,  thus  producing  a  brighter  and 
steadier  light  (Fig.  9). 


20 


THE    RONTGEN    RAYS 


The  best  tubes  are  those  which,  when  new,  show  a  red-hot 
focus  at  the  platinum  disk  while  a  low  current  is  employed.    New 


Fig.  8 — Regulating  Tube. 


tubes  that  show  fluorescence  only  when  a  high  current  is  used 
should  be  rejected.  It  is  one  of  the  main  characteristics  of  a  good 
tube  that  it  stands  intense  glowing  of  the  platinum  disk  without 


Fig.  9.— Regulating  Tube  in  Use. 


THE    APPAKATUS 


21 


being  impaired  after  a  few  seconds;  in  other  words,  thai  it  stands 
currents  of  high  intensity.  A  good  tube  must  also  furnish  a  uni- 
form light. 

The  variety  of  tubes  now  manufactured  in  various  parts  of  the 
world  is  very  great.  It  seems  to  the  writer  that,  while  the  best  coils 
are  made  in  this  country,  Germany  still  furnishes  the  best  tubes. 
It  must  also  be  considered  that  it  requires  a  vast  amount  of  expe- 
rience and  repeated  experimentation  to  select  tubes  suitable  for 
the  particular  apparatus  employed.  Static  machines,  as  alluded 
to  before,  require  tubes  with  a  special  vacuum,  while  tubes  pre- 
pared for  a  battery  set  generally  do  not  give  satisfaction  with  an 
air-brake  wheel  apparatus  or  a  Wehnelt  interrupter,  which  per- 


Fig.  10. — Grunmach-Kny  Tube  provided  with  Water-cooling  Apparatus. 


mits  the  use  of  the  highest  vacuum  obtainable  at  present.  Tubes 
must  be  carefully  studied,  individualized,  so  to  speak,  just  as 
different  patients  are  to  be  judged  differently,  although  suffering 
from  the  same  disease. 

In  order  to  prevent  overheating,  Grunmach  advised  tubes  pro- 
vided with  a  circulation  of  a  stream  of  cold  water.  Thus  the  glow- 
ing metal  is  cooled  off,  and  the  vacuum  cannot  be  lowered  by  the 
heat  radiating  from  the  anticathode.  A  good  tube  of  this  kind  is 
constructed  by  Kny  (Fig.  10). 

Walter  constructed  tubes  of  large  size  which  permit  of  chang- 
ing a  pint  of  water  into  vapour.  These  tubes  excel  by  their 
strongly  marked  focussing  point.  The  vacuum  of  a  tube  of  this 
kind  shows  more  stability  than  any  other.  The  largest  consists 
of  a  platinum  cap  which  is  sealed  in  the  end  of  a  glass  tube.    This 


22  THE    UOiNTGEN    KAYS 

projects  within  the  bulb,  while  outside  of  it  it  is  enlarged  into  a 
small  bottle  for  containing  the  cooling  fluid.  This  adjustment 
permits  of  the  fluid  coming  in  contact  with  the  target.  Tubes  of 
this  kind  give  splendid  results,  and  it  is  deplorable  that  the  tech- 
nical difficulties  connected  with  their  construction  make  their  price 
extremely  high. 

Tubes  must  be  preserved  in  a  closet  in  which  there  is  a  uni- 
form medium  temperature.  They  should  rest  on  padded  shelves. 
Dust,  which  in  the  course  of  time  always  becomes  adherent  to  the 
tube  while  in  use,  is  to  be  wiped  off  by  passing  the  dry  palm  of  the 
hand  gently  over  it. 

The  Vacuum  of  the  Rbntgen  Tube. — As  alluded  to  before,  if 
the  intratubal  pressure  is  reduced  to  its  utmost,  if,  in  other  words, 
the  degree  of  evacuation  is  very  high,  we  speak  of  a  high  vacuum. 
As  a  rule  such  tubes  are  called  hard.  It  is  assumed  that  the  paths 
followed  by  atoms  repelled  from  the  cathode  are  free  from  ob- 
struction, so  that  they  can  strike  their  points  of  destination  with 
great  rapidity,  thus  producing  small  wave  lengths  which  penetrate 
matter  freely.  This  accounts  for  the  great  power  of  penetration. 
If  the  intratubal  pressure  is  reduced  to  a  lesser  degree,  so  that  a 
comparatively  large  amount  of  air  remains  inside  of  the  tube,  we 
speak  of  a  low  vacuum.  Tubes  showing  a  low  vacuum  are  called 
soft.  Since  a  greater  number  of  atoms  radiate  in  all  directions, 
the  points  of  destination  are  touched  with  less  velocity.  Thus  the 
production  of  short  wave  lengths  is  prevented  and  the  free  pass- 
ing obstructed.  Consequently  dense  objects  are  not  penetrated 
by  the  rays  of  tubes  of  this  type,  and  the  objects  are  never  able  to 
absorb  their  rays. 

So  we  learn  that  the  intensity  of  the  rays  increases  in  propor- 
tion to  the  height  of  the  vacuum.  If  very  high  vacua  are  used, 
even  the  bones  of  the  hand  may  become  so  translucent  that  they  can 
hardly  be  distinguished  on  the  plate,  while  too  low  a  vacuum  does 
not  generate  any  Eontgen  rays  at  all,  the  current  passing  the  tube 
by  forming  cathode  rays.  Thus  it  will  be  understood  why,  for 
the  representation  of  the  bones  of  the  hand,  a  tube  with  a  low 
vacuum  (so-called  soft  tube)  is  to  be  chosen,  while  if  the  rays 
must  permeate  a  very  thick  body,  such,  for  instance,  as  the  pelvis  of 
a  fat  person,  it  is  the  high  vacuum  tube  (hard  tube)  that  would 
be  capable  of  throwing  so  much  light  through  it  as  to  show  a  well- 
defined  shadow  on  the  plate.     From  these  facts  we  appreciate  that, 


THE    APPARATUS  23 

according  to  the  thickness  and  permeability  of  the  object  to  be 
skiagraphed,  tubes  of  low,  medium,  high,  and  very  high  vacuum 
must  be  at  hand. 

The  degree  of  the  tubal  vacuum  is  unstable.  At  first  a  tube 
becomes  softer  when  in  use,  because  the  particles  of  air  which 
adhere  to  the  tubal  wall  are  detached  from  it  by  the  warming  influ- 
ence of  the  current.  After  the  tube  is  cooled  off,  it  becomes  harder 
again,  because  the  particles  of  platinum  dissipated  from  the  glow- 
ing anticathode,  while  cooling,  find  particles  of  air  in  the  interior 
of  the  tube.  The  longer  the  tube  is  in  use  the  more  air  is  hound 
by  this  process,  so  that  the  amount  of  the  intratubal  air  finally 
becomes  too  small  to  permit  the  passing  of  a  current.  Tubes  of 
this  kind  are  characterized  by  the  dark-brown  deposits  in  the  in- 
tratubal walls,  which  were  produced  by  the  dissipated  particles  of 
the  platinum.  The  degree  of  a  vacuum  is  in  proportion  to  the 
length  of  the  spark.  The  higher  the  degree  of  evacuation  there- 
fore is  the  larger  the  length  of  the  spark,  and  consequently  the 
harder  the  tube  must  be.  The  lower  the  evacuation,  the  shorter 
the  spark  length  and  the  softer  the  tube. 


CHAPTER    II 
RONTGEN  TECHNIQUE 

Methods  of  Measuring'  the  Degree  of  the  Vacuum. — In  order 
to  estimate  the  intensity  of  the  rays  and  the  amount  of  their  pene- 
tration various  kinds  of  skiameters  were  advised.  The  principle 
of  these  instruments  consists  in  the  insertion  of  an  obstacle  to 
the  rays.  This  is  accomplished  by  attaching  small  squares  of  tin- 
foil, of  various  thicknesses,  to  a  fluorescing  screen.  The  difference 
of  thickness  is  indicated  by  little  figures '  made  of  lead,  which 
appear  more  or  less  distinct  according  to  the  thickness  of  their 
corresponding  tinfoil.  The  author  had  found  it  useful  to  con- 
struct a  skiameter  consisting  of  50  staniol  disks.  To  each  disk  a 
number,  made  of  wire,  is  attached,  which  indicates  the  number  of 
the  staniol  lamella?.  N~o.  1,  for  instance,  contains  one  lamella 
only;  while  No.  50  contains  50.  That  number  which  just  permits 
the  recognition  of  the  shadow  of  its  wire  cipher  indicates  the 
degree  of  the  intensity  of  the  tube.  Most  operators,  however, 
prefer  to  test  the  vacuum  of  the  tube  by  simply  holding  their 
own  hand  before  the  fluorescing  screen.  In  fact,  the  hand  is  a 
most  reliable  indicator,  since  it  contains  many  different  types  of 
bones,  from  the  massive  carpal  end  of  the  radius  to  the  delicate 
third  phalanx  of  the  little  finger.  But  such  tests  lead  to  patholog- 
ical changes  of  the  integument,  which  may  become  permanent, 
and  may  even  lead  to  the  loss  of  the  extremity.  The  detailed 
description  of  these  changes,  as  well  as  of  the  means  of  protec- 
tion, is  found  in  Chapter  XVIII  on  the  Therapeutic  Effects  of  the 
Rontgen  Rays. 

Recently  Walter  has  constructed  a  skiameter,  the  metallic  plates 
of  which  are  made  thicker  in  proportion  to  geometric  instead  of 
arithmetic  progression.  For  the  tinfoil  platinum  is  substituted. 
Then  but  a  small  number  of  lamellae  is  required,  which  renders 
numbering  superfluous.  Walter  uses  eight  apertures.  The  fluores- 
cent screen  placed  before  the  disk  shows  one  lamella  only  when  a 
24 


RONTGEN    TECHNIQUE 


25 


very  .soft  tube  is  employed,  while  all  lamellae  are  recognised  if  a 
very  hard  tube  is  selected. 

The  photometric  scale  of  Benoist  also  permits  a  minute  pre- 
cision of  the  degree  of  the  vacuum,  but  needs  further  modification 
to  become  useful  in  practice.  Its  principle  is  based  upon  the  trans- 
parency of  the  metals  with  an  atomic  weight  of  100  to  150,  sil- 


Fig.  11.— Author's  Osteoscope. 


ver,  for  instance,  varying  in  a  lesser  degree  than  the  other  ele- 
ments in  regard  to  the  radiations  of  tubes  of  different  vacua. 

An  experienced  operator  is  often  able  to  estimate  the  degree 
of  the  vacuum  by  simple  inspection,  the  colour  of  the  light,  and 
its  division,  the  mode  of  induction,  the  character  of  the  noise  of 
the  apparatus  in  combination  with  minor  signs  being  the  indica- 
tions of  quality. 

Still,  as  the  wrinkled  and  shrivelled  Eontgen  hands  of  physi- 
cians (compare  Fig.  245)  show,  who  employ  the  method  fre- 
quently, the  danger  of  continuous  exposure  is  great.  As  empha- 
sized in  Section  III  on  Rontgen-Eay  Therapy,  even  apparatus 
like  the  ingenious  chromoradiometer  of  Holzknecht,  or  the  radio- 
chromometer  of  Benoit,  or  the  ampoule  osmo-regulateur  of  Vil- 


26 


THE    RONTGEN    RAYS 


lard,  in  their  present  shape,  proved  to  have  only  a  limited  field 
of  usefulness. 

As  said  above,  men  of  great  experience  are  able  to  estimate  by 
the  general  appearance  of  the  light.    But  this  is  certainly  not  reli- 


Fig.  12. — Controlling  the  Vacuum  by  tue  Osteoscope  during  Exposure. 


able.  With  the  Walter  combination  the  degree  of  the  vacuum  can 
approximately  be  estimated  by  the  arrangement,  but  this  is  compli- 
cated and  not  favoured  by  the  average  practitioner. 

Instead  of  sacrificing  the  living  extremity  of  physician  or 
patient,  the  author  has  suggested  to  utilize  the  skeleton.  His  osteo- 
scope will,  in  fact,  be  found  to  answer  all  practical  purposes.1  The 
bones  of  the  forearm  and  hand  are  fastened  to  a  sheet  of  paste- 
board or  similar  translucent  material,  by  being  inserted  in  the 
frame  of  a  fluorescent  screen  it  can  be  moved  to  and  fro,  so  that 
the  phalanges,  the  carpus,  or  elbow  can  be  studied.  To  make  the 
apparatus  more  compact,  besides  the  hand  only,  the  epiphyseal 
ends  of  the  forearm  may  be  utilized.  When  the  hiatus  between 
the  eminentia  capitata  and  the  radial  head  is  distinctly  shown, 
sufficient  contrast  can  be  expected  on  the  plate    (Fig.   11). 

1  The  osteoscope  is  made  by  Max  Kohl  of  Chemnitz. 


RONTGEN    TECHNIQUE 


27 


The  elbow  is  a  better  mentor  than  the  wrist,  if  permeation  of 
thick  tissues  is  considered,  dust  as  in  the  living  carpus  the  bones 
appear  black  if  a  soft,  and  light  gray  if  a  hard  tube  is  chosen.  The 
handle  of  the  osteoscope  is  surrounded  by  a  shield  of  lead,  so  that 
the  hand  is  perfectly  protected  while  holding  it.  It  i>  no  small 
advantage  of  the  osteoscope  that  only  one  hand  is  needed  for 
manipulation.  The  hones  of  the  apparatus  may  he  hidden  under 
black  muslin  or  pasteboard.     By  attaching  a  tapering  box  to  the 


Fig.  13. — Lateral  Dislocation  of   Elbow  and  Old   Fracture  of  External 

Condyle. 


frame,  like  the  one  used  with  the  fluoroscope,  the  osteoscope  can 
also  be  used  in  a  light  room   (Fig.  12). 

As  mentioned  in  the  foregoing  chapter,  it  is  desirable  to  dis- 
tinguish hard   and   soft  tubes  from  those   of   medium  hardness. 


28 


THE    RONTGEN    RAYS 


If  a  tube  shows  the  bones  of  the  osteoscope  light  gray  and  trans- 
lucent, it  is  of  excessive  hardness,  the  contrasts  are  insignificant 
then,  and  it  is  practically  useless  for  Rontgen  examination.  Tubes 
of  this  kind  take  a  skiagraph  of  a  hand  in  one  second,  and  of  a 
pelvis  in  ten,  but  there  is  no  contrast,  the  image  being  blurred  and 
foggy.  Under  extraordinary  circumstances  they  may  be  used  for 
the  representation  of  metallic  foreign  bodies,  when  the  osseous 
structures  do  not  need  consideration.  Fig.  13,  for  instance,  illus- 
trates  the  indistinct   skiagraph    of   a   lateral   dislocation   of   the 


Fjg.  14. — Normal  Ankle-joint,  taken  with  a  Tube  of  Medium  Hardness. 

elbow-joint.  Tubes  of  this  kind  show  little  fluorescence,  and  if 
excessively  hard,  no  rays  are  produced  at  all.  The  amount  of 
fluorescence  can  be  estimated  from  the  depth  of  shading  which 
is  given  to  the  lower  part  of  the  Rontgen  tube.     There  is  a  large 


RONTGEN    TECHNIQUE  29 

amount  of  secondary  rays  and  of  ozone.     The  spark  often  jumps 
around  the  tube. 

A  tube  of  medium  hardness  is  the  tube  par  excellence.     It 
shows  the  bones  of  the  wrist,  especially  the  lower  radial  epiphysis, 


Fig.  15. — Fracture  of  Lower  End  of  Radius  followed  by  Displacement, 
taken  with  a  soft  tube. 

grayish-black,  but  the  contrasts  are  marked  and  the  structures 
well  outlined.  Such  tubes  are  especially  fit  for  the  representation 
of  thick  bones,  and  of  renal  concretions.  The  fluorescence  finds 
its  expression  in  the  deeper  shading  of  the  globe.  There  is  exterior 
discharge  to  a  lesser  degree  than  in  the  former  variety.  Therefore 
a  tube  of  this  degree  of  vacuum  cannot  be  touched  without  receiv- 
ing a  shock.  The  picture  from  such  a  tube,  which  shows  the  bony 
structure,  is  illustrated  by  Fig.  14. 


30 


THE    RONTGEN    RAYS 


A  soft  tube  shows  the  outlines  of  the  phalanges  and  the  meta- 
carpus black  and  the  soft  tissue  dark.  There  is  bright  fluorescence 
and  marked  contrast  on  the  screen.    But  the  denser  portions  of  the 


Fig.  16. — Paint  Indication  of  Bullet  in  the  Os  Magnum  and  Evidence  of 
Small  Fragments  in  the  Carpus  (Low  Vacuum  Tubk).  (Compare  Figs. 
17  and  18.) 

bones  are  not  penetrated.     Therefore  tubes  of  this  kind  produce 
excellent  skiagraphs  of  the  bones  of  the  hand  and  forearm,  but  are 


RONTtiEN    TECH  XI  QUE 


31 


not  powerful  enough  to  represent  structural  details.  A  skiagraph 
taken  with  a  soft  tube  is  illustrated  by  Fig.  15.  Excessively  soft 
tubes  produce  violet  light  and  show  the  carpus  as  black  as  ink, 
no  contrast  being  recognisable  at  all.  Tubes  of  this  kind  can  be 
touched  without  receiving  a  shock. 

The  various  degrees  were  also  illustrated  by  the  author  in  his 
publication  on  Tenontitis  and  Tenontothecitis.     New  York  Med 
ical  Journal,  April  27,  1901. 

How  to  interpret  the  different  vacua  is  also  illustrated  practi- 


Fig.  17. — Bullet  Case,  illustrated  by  Fras.   16  and  18,  Lateral  Exposure 
(Low  Vacuum  Tcbe). 


cally  by  the  simple  case  of  a  man  of  twenty-four  years  who  was 
shot  eleven  years  before  the  skiagraphs  jSTo.  16,  17,  and  18  were 
taken.  Fig.  16  shows  a  very  faint  indication  of  the  presence 
of  the  bullet  in  the  os  magnum,  while  the  small  fragments  in  the 
carpus  are  recognisable,  a  low-vacuum  tube  having  been  chosen. 
The  hand  rested  on  the  palm.  The  bullet  being  near  the  dorsal 
surface  and  the  small  fragments  near  the  palm,  it  is  appreciated 
why  the  latter  are  recognised  in  spite  of  the  low  vacuum.  Fig.  17, 
also  taken  with  a  low- vacuum  tube  in  the  lateral  position,  was  ex- 


32 


THE    RONTGEN    EAYS 


posed  ten  seconds  longer.  It  shows  the  bullet  a  little  more  dis- 
tinctly. The  fragments  are  also  visible.  Fig.  18  was  also  taken  in 
the  lateral  position,  but  this  time  a  tube  of  medium  hardness  was 
used.  This  accounts  for  the  distinct  representation  of  the  bullet  in 
the  os  magnum,  from  which  it  was  extracted  after  being  mobilized 
by  the  chisel.  The  bones  appear  black  in  Figs.  16  and  17,  while 
Fig.  18  appears  gray,  the  bony  structures  being  indistinct.  The 
patient  was  not  disturbed  for  eleven  years,  and  the  author  would 
not  have  advised  extraction  if  there  were  not  a  slight  inflamma- 


Fig.    18. — Bullet  Case,   illustrated  by  Figs.    16   and   17,    showing   Bullet 
Distinct  and  Bones  Translucent  (Tdbe  of  Medium  Hardness). 


tory  process  induced  by  an  injury,  which  caused  the  patient  con- 
siderable disturbance. 

By  studying  the  three  skiagraphs  the  seat  of  the  bullet  was 
made  out  without  measuring. 

The  Handling  of  Tubes  in  Connection  with  the  Wehnelt  In- 
terrupter.— It  is  highly  recommended  to  have  a  number  of  tubes  at 
one's  disposal,  so  that  fresh  tubes  can  always  be  used.  The  vacuum 
of  a  tube  is  affected  after  being  used,  therefore  it  is  desirable  to 
have  another  tube  on  hand  in  case  a  second  exposure  is  required. 
As  alluded  to  before,  the  success  of  a  Rontgen  examination  de- 
pends largely  upon  the  proper  degree  of  vacuum  and  the  time  of 
exposure.     The  character  of  the  current  can,  as  described  above, 


RONTGEN    TECHNIQUE  33 

approximately  be  estimated  by  the  appearance  of  the  tubal  Light. 
If  a  Wehnelt  interrupter  is  employed,  it  may  be  said  that  but  a 
slight  greenish  fluorescence  without  a  marked  division  of  the 
luminous  cone  is  noticed  if  there  be  an  undercharge.  There  may 
also  be  frequent  irregularity  in  the  interruption.  The  cause  may 
be  twofold.  Either  the  current  employed  is  too  weak,  or  the  mode 
of  self-induction  is  improper.  If  the  function  of  the  tube  appears 
to  be  regular,  but  if  the  current  is  too  weak,  a  slight  increase  of  the 
primary  current  is  indicated.  On  the  other  hand,  if  there  is  good 
fluorescence  and  normal  division,  but  the  induction  is  irregular, 
the  spark  length  of  the  tube  being  larger  than  the  one  produced 
by  the  self-induction  of  the  inductor,  the  latter  must  be  reduced. 

If  there  be  regular  but  weak  function,  which  does  not  react  on 
a  stronger  current,  self-induction  is  insufficient,  the  wire  of  the 
Wehnelt  interrupter  not  projecting  far  enough.  This  condition  is 
remedied  by  increasing  the  current  and  by  lengthening  the  plati- 
num tip. 

If  there  be  an  overcharge  the  anticathode  soon  begins  to  glow, 
thus  lowering  the  vacuum  so  much  that  the  tube  becomes  practi- 
cally useless.  If  the  current  is  not  stopped,  the  anticathode  be- 
comes white  hot  and  a  hole  is  melted  through  the  platinum,  while 
there  is  flickering  light,  ring  formation,  and  crepitation  ;  once  in 
a  while  there  are  rays  of  great  power  of  penetration,  but  as  a  rule 
no  rays  are  generated  at  all.  In  such  an  event  the  primary  cur- 
rent was  too  strong  or  the  platinum  tip  projected  too  far,  so  that 
the  spark  became  too  thick. 

Diaphragms. — The  fact  that  the  currents  are  not  unidirec- 
tional, sometimes  even  the  whole  of  the  tube  becoming  a  source 
of  the  Rontgen  rays,  has  given  an  impetus  to  the  construction  of 
lead  diaphragms,  which  do  not  permit  a  larger  amount  of  light  to 
pass  than  the  reproduction  of  the  area  to  be  traversed  requires. 
Thus  the  injurious  secondary  rays  are  kept  off,  the  effective  cone 
of  light  only  being  projected  on  the  plate. 

Thick  portions  of  the  body  reflect  the  rays  diffusely.  So,  for 
instance,  in  making  an  exposure  of  the  pelvis  of  a  fat  individual 
each  muscular  portion  irradiates  the  whole  plate  individually,  so 
that  the  contrast  is  considerably  diminished.  The  fact  that  soft 
tubes  are  least  apt  to  diffuse  the  rays  would  naturally  suggest 
their  exclusive  use.  But  their  small  power  of  penetration  makes 
them  unfit  for  representing  thick  layers. 
4 


34 


THE    KONTGEN    EAYS 


The  introduction  of  the  methodical  use  of  the  diaphragm  marks 
a  great  advance  in  the  Kontgen  technique.     It  is  only  possible  by 


a       a 
Fig.  19. — Plate  Diaphkagm. 


Tubular  diaphragm 


Pig.  20. — Tubular  Diaphragm. 


these  means  that  the  structural  details  of  thicker  portions  of  the 
body  can  be  well  reproduced.  Especially  in  diagnostic  differentia- 
tion the  value  of  the  diaphragm  method  is  immense.     Errors,  as 


Fig.  21.— Simple  Form  of  Lead  Diaphragm. 

they  are  illustrated  in  the  chapter  on  the  medico-legal  aspects  of 
the  Kontgen  rays,  are  simply  impossible.  Bone-fissures  cannot 
escape  detection. 


KONTGEN    TECHNIQUE 


35 


The  original  diaphragm  con- 
sisted simply  of  a  sheet  of  lead 
into  which  a  hole  was  cut.  Fig. 
19,  for  instance,  shows  a  dia- 
phragm of  a  diameter  of  2  inch- 
es, which  is  traversed  hy  the  rays 
emanating  from  a  tube  placed 
above.  Besides  the  rays  from 
the  target  (aa),  those  emanat- 
ing from  the  tubal  wall  (bb) 
pass  the  hole  in  the  diaphragm. 
Thus  a  certain  amount  of  diffu- 
sion is  still  produced.  To  obvi- 
ate this,  tubular  diaphragms 
were  constructed  which  permit 
the  passing  of  the  focal  rays 
only,  those  emanating  from  the 
tubal  wall  being  excluded.  Fig. 
20  shows  the  principle  of  the 
tubular  diaphragm,  which  is 
passed  by  the  focal  rays  (aa),  while  the  rays  emanating  from  the 
tubal  wall  (bb)  are  reflected. 

The  use  of  the  simple  form  of  a  lead  diaphragm  is  illustrated 
by  Fig.  21. 

Albers-Schoenberg  deserves  great  credit  for  having  constructed 
a  compression  diaphragm  (Fig.  22),  which  not  only  prevents  diffu- 


FlG. 


22.  —  Simple    Compression    Dia- 
phragm. 


Fig.  23.— Skiagraphing  Renal  Calculi  bt  using  the  Compression  Diaphragm. 


Fig.  24. — Examining  the  Foot  by  the  Compression  Diaphragm. 


Fig.  25. — Author's  Movable  Diaphragm. 


Fig.  26. — Textural  details  shown  by  the  aid  of  Author's  Diaphragm  in 
Fracture  of  Radius,  Associated  With  Fracture  of  Styloid  Process 
of  Ulna. 


Fig.  27. — Skiagraphing  Hand  by  the  aid  of  Author's  Diaphragm. 


38 


THE    KOXTGEN    EAYS 


sion,  but  also  permits  immobilization  of  the  area  to  be  irradiated 
by  compression,  a  decided  advantage  of  the  latter  also  consisting 
in  the  possibility  of  bringing  the  area  nearer  to  the  photographic 
plate.  The  compression  also  has  the  great  advantage  that  all  ex- 
posures are  taken  at  the  same  distance  of  the  tube  from  the  surface 
of  the  body.    Thus  an  exact  standardization  is  guaranteed,  and  the 


Skiagraphing  Head  by  the  aid  of  the  Diaphragm. 


perspective  always  remains  the  same.  The  elaborate  metallic  com- 
pression-diaphragm illustrated  by  Figs.  23  and  2-i  is  movable  in 
any  direction.  Its  diameter  is  proportional  to  the  size  of  the  skia- 
graph to  be  made.  Tubes  provided  with  various  diameters  are 
therefore  recommendable.  In  general,  however,  a  diameter  of  4 
inches  is  desirable.  Even  in  fat  persons  structural  details  can  be 
obtained  with  this  apparatus. 


RONTGEN    TECHNIQUE  39 

No  perfect  Rontgen  outfit  can  be  without  a  compression  dia- 
phragm nowadays,  the  only  drawback  being  that  the  splendid  appa- 
ratus of  Albers-Schonberg  is  extraordinarily  high  priced.  The 
author  has  therefore  devised  a  simple  movable  tube  (Figs.  ".■>.  26, 
27,  and  28),  which  is  portable  and  can  be  fastened  to  any  table, 
and  practically  answers  the  same  purpose.  It  prevents  diffusion 
and  permits  of  immobilization  and  compression.  Its  cheap  price 
places  it  within  the  reach  of  every  physician.1  (The  upper  margin 
of  the  tube  of  the  diaphragm  must  be  wider  than  it  appears  on  the 
illustrations.)  The  tube  can  be  made  in  three  diameters  of  various 
size. 

1  The  apparatus  is  made  by  Friedrich  Droll  of  Heidelberg. 


CHAPTER    III 
FLUOROSCOPY 

The  Field  of  Fluoroscopy  (R'ontgoscopy). — In  the  introduc- 
tion, page  1,  it  is  described  that  the  rays  in  falling  upon  a  screen 
which  is  covered  with  fluorescing  salts,  such  as  tungstate  of  cal- 
cium or  platinocyanide  of  barium,  cause  fluorescence  on  it.  The 
human  hand,  for  instance,  if  placed  between  the  tube  and  a  screen 
evenly  covered  with  one  of  the  fluorescing  salts,  shows  the  condition 
of  its  bones.  Even  the  soft  tissues  can  be  distinguished  to  some 
extent.  There  are  many  other  salts  fluorescing  under  the  Rontgen 
rays,  but  up  to  the  present  day  the  platinocyanide  of  barium,  as 
it  was  first  used  by  Rontgen,  has  proved  to  be  the  best  fluorescing 
material.     It  gives  a  yellowish-green  and  brilliant  fluorescence. 

The  use  of  the  fluorescing  screen  is  facilitated  by  attaching  it 
to  a  suitable  framework  formed  like  that  of  a  stereoscope,  the 
body  of  which  is  of  a  tapering  form.  The  large  end  of  such  an  in- 
strument, generally  called  fluoroscope,  contains  a  piece  of  card- 
board on  the  inner  surface  of  which  the  fluorescent  salt  is  distrib- 
uted, while  the  small  end  of  the  apparatus  has  two  apertures 
formed  in  such  a  manner  as  to  fit  over  the  eyes  of  the  operator. 
The  pasteboard  is  liable  to  contamination  and  injury  if  suppurat- 
ing or  wounded  areas  must  be  examined.  In  such  cases  it  is  advis- 
able to  cover  it  with  a  non-absorbent  material  which  permits  of 
sterilization,  such  as  very  thin  sheet  celluloid,  for  instance.  If 
used  during  a  surgical  operation,  the  hood  should  also  be  covered 
with  a  material  which  can  be  sterilized.  Hard  rubber  may  be  used 
for  this  purpose.  For  examining  the  largest  parts  of  the  body 
the  screen  should  have  a  dimension  of  about  12  to  18  inches. 

For  examination  with  the  screen  a  room  must  be  chosen  which 
can  be  darkened  at  will.    If  there  is  colour  sensitiveness  for  green, 
the  operator  will  finrl  the  tungstate  fluoroscope  more  satisfactory 
than  that  of  the  barium. 
40 


FLUOROSCOPY 


41 


A  rough  sketch  may  be  obtained   from  the  screen   by  simply 

tracing  (Fig.  29). 

The  advantages  of  the  screen  are  obvious.  In  the  first  place, 
there  is  no  necessity  for  a  previous  exposure,  and  the  development 
of  a  photographic  plate,  as  in  skiagraphy.  Secondly,  the  irradiated 
area  can  be  examined  while  it  is  in  action.  Thus  the  motions  of 
the  joints,  the  larynx,  the  hy- 
oid  bone,  furthermore  the  pul- 
sation of  the  heart,  the  lungs, 
the  diaphragm,  etc.,  can  be 
thoroughly  studied.  Espe- 
cially the  continuous  motions 
of  heart  and  lungs  are  an  im- 
pediment for  distinct  skia- 
graphy, while  they  are  a  direct 
aid  in  diagnosis  if  watched  by 
the  screen.  The  excursions  of 
the  diaphragm  during  inspira- 
tion and  expiration  can  be 
noted  and  measured. 

A  fluoroscopic  examination 
should  also  precede  the  skia- 
graphic  exposure  as  a  kind  of 
preliminary  survey.  This  is 
especially  important  in  fract- 
ures and  dislocations,  since  it 
calls  attention  to  the  seat  of 
the  injury.  It  furthermore 
determines  the  best  position 
of  the  limb  for  proper  fixa- 
tion during  skiagraphic  expo- 
sure,   so,    for    instance,    that 

angle  of  flexion  or  extension  in  which  the  injured  portion  can 
be  brought  out  best  on  the  plate. 

This  shows  the  greater  importance  of  fluoroscopic  examination 
in  internal  medicine,  while  in  surgical  practice  its  usefulness  is 
limited  because  of  the  production  of  the  numerous  fluorescing 
impressions,  which,  by  succeeding  each  other  with  great  rapidit}r, 
are  apt  to  deceive  the  human  eye  wherever  the  features  of  the  lesion 
are  not  distinctly  marked.     Fixation  of  the  condition  to  be  exam- 


Fig.  29.— Tracing  Apparatus. 


42  THE    RONTGEN"    RAYS 

ined  on  a  photographic  plate  (skiagraphy)  is  therefore  to  be  pre- 
ferred as  a  rule. 

In  thin  areas  of  the  body,  however,  like  the  hand,  projectiles 
or  needle-fragments  are  so  well  shown  by  the  screen  that  a  skia- 
graph is  a  mere  luxury  as  a  rule.  Fluoroscopy  also  permits  the 
examination  of  an  extremity  while  it  is  turned  in  various  direc- 
tions. The  superficial  localization  of  foreign  bodies  is  facilitated, 
as  it  is  ascertained  whether  it  is  situated  in  front  or  behind  a 
bone,  etc. 

But  in  making  a  thorough  examination  of  the  thigh,  the  shoul- 
der, and  the  large  cavities  of  the  body  for  foreign  bodies,  fluoros- 
copy should  not  be  relied  upon.  Fractures  are  recognised  by  the 
screen  only  if  there  is  displacement.  But  if  the  fragments  re- 
mained in  apposition  the  fragment  line  is  indistinct.  If  it  must 
simply  be  ascertained  through  a  plaster-of-Paris  dressing  whether 
the  fragments  are  in  exact  apposition  after  reduction,  fluoroscopic 
examination  is  sufficient  as  a  rule,  since  it  is  not  necessary  to  see 
the  fracture  line  then.  The  salient  point  is  simply  to  verify 
whether  the  bones  were  reduced  in  the  proper  direction.  (Com- 
pare Chapter  XV  on  Fractures.) 

In  some  forms  of  dislocation  the  screen  gives  ample  informa- 
tion. Dislocation  of  the  shoulder- joint,  for  instance,  may  be  recog- 
nised at  once  on  the  screen,  while  the  result  of  the  palpatory  exam- 
ination was  rendered  uncertain  by  the  presence  of  a  large  bloody 
effusion.  On  the  other  hand,  the  dislocation  of  a  small  bone,  like 
rthe  radical  head,  in  so  complicated  a  joint  as  that  of  the  elbow  is, 
may  be  overlooked  or  misinterpreted  on  fluoroscopic  examina- 
tion. In  dislocation  of  the  hip  fluoroscopy  must  also  not  be 
trusted.  The  same  can  be  said  of  the  detection  of  concretions  and 
of  the  diseases  of  the  teeth  and  the  bones  as  they  are  described  in 
Chapter  VI  and  XIII. 

As  a  rule,  hard  tubes  should  not  be  employed  for  screen  work 
on  account  of  their  great  penetrating  power,  which  permits  but 
little  contrast.  Soft  tubes  give  the  best  fluoroscopic  differentia- 
tion. Especially  in  studying  the  thoracic  organs  this  kind  of 
tubes  should  be  chosen.  If  thicker  portions  of  the  body  must  be 
examined,  tubes  of  medium  hardness  are  required.  The  mobility 
of  the  tube  is  a  condition  sine  qua  non  in  fluoroscopic  examina- 
tion. The  tube-holder  must  be  so  arranged  that  the  tube  can  be 
turned  in  all  directions.     The  author's  diaphragm,  as  described 


FLUOROSCOPY 


43 


on   page   39,    is  also   extremely    useful    for   detailed    observation 
in  fluoroscopy.     An  advantage  of  fluoroscopy  not  to  be  underesti- 

m 


Fig.  30.— Orthodiagraphy  Examination. 


mated  is  its  cheapness.  A  disadvantage  of  the  screen  for  patient 
and  physician  is  the  necessity  of  long  exposure,  which  may  once 
in  a  while  result  in  dermatitis. 


44 


THE    KONTGEN    EAYS 


Orthodiagraphy. — The  fact  that  the  size  of  all  skiagraphs  is 
larger  than  that  of  the  objects  they  represent,  led  to  the  construc- 
tion of  orthodiagraphic  apparatus,  by  the  aid  of  which  the  exact  size 
of  a  body  is  determined.  Levy-Dorn,  Moritz,  Hirschmann,  and 
others  have  constructed  useful  apparatus  of  this  kind.  The  ortho- 
diagraph made  by  Hirschmann  permits  direct  tracing  by  the  aid  of 
a  movable  screen  (compare  Fig.  30).  The  measuring-stand  devised 
by  Hoffmann  (Fig.  31)  has  also  come  into  favour.    Its  main  prin- 


Fig.  31. — Hoffman's  Measuring  Stand. 


ciple  consists  in  the  construction  of  registering  wire  screens  which 
can  be  moved  in  various  directions.  Apparatus  of  this  kind,  how- 
ever, permit  only  of  measuring  the  shadow  of  the  foreign  body, 
while  its  natural  size  must  be  guessed  at. 

Donath's  modification,  which  allows  the  movement  of  the  tube 
above  a  millimetre  scale,  the  tube  being  placed  perpendicularly  at  a 
measured  distance,  gives  very  nearly  the  exact  size  of  a  foreign 
body. 


CHAPTEE    IV 
SKIAGRAPHY 

Skiagraphy  (Rontgography).1 — As  previously  stated,  skiag- 
raphy is  based  on  the  photographic  effects  which  are  produced  by 
the  Rontgen  rays.  Its  main  advantages  arc  the  possibility  of  per- 
manently retaining  and  recording  the  shadow  thrown  on  the  sen- 
sitized plate.  In  fact,  structural  details  can  be  shown  exactly  on 
the  photographic  plate,  and  it  is  the  skiagraph  only  which  permits 
the  thorough  study  of  the  various  features  of  a  lesion.  Its  com- 
parison with  the  normal  skeleton  will  make  the  abnormalities  evi- 
dent at  once,  and  will  help  the  physician  to  a  thorough  judgment  of 
the  case.  In  addition,  the  value  of  a  skiagraph  for  future  infor- 
mation— especially  in  case  of  complicated  fracture  for  forensic 
purposes — should  not  be  underestimated.  Therefore  whenever 
exactness  of  result  is  desired,  fixation  on  a  photographic  plate  is  to 
be  preferred.     The  photographic  technique  can  easily  be  learned. 

It  is  well  known  that  if  silver  is  combined  with  bromine  or 
chlorine,  bromide  or  chloride  of  silver  is  formed.  This  combina- 
tion has  the  property  of  being  sensitive  to  light,  and  the  chem- 
ical decompositions  taking  place  while  it  is  exposed  to  the  light 
cause  a  change  of  colour.  For  proper  utilization  in  photography 
the  salts  of  silver  are  mixed  with  hard  white  gelatin.  On  a  sur- 
face consisting  of  either  glass  or  paper  or  celluloid  this  composi- 
tion is  spread,  thus  constituting  what  is  called  a  sensitive  plate 
or  paper  or  film.  The  image  received  by  the  sensitive  plate  or 
film  is  invisible,  and  must  be  treated  by  a  peculiar  chemical  proc- 
ess, called  development,  in  order  to  bring  it  out.  The  developing 
process  of  a  skiagraphic  plate  is  practically  the  same  as  that  of 
an  ordinary  photographic  plate  exposed  to  sunlight.  There  is  no 
doubt  that  the  anatomical  knowledge  of  a  physician  makes  him 
more  fit  to  develop  the  important  parts  of  a  plate  properly.     It  is 

1  The  author  objects  to  the  much-favoured  expression  "radiography," 
which,  as  many  other  modern  terms  constructed  by  violent  word-composers, 
is  a  hybrid. 

45 


46  THE    KONTGEN    RAYS 

a  great  advantage  besides  if  the  physician  is  able  to  develop  the 
plates  himself,  since  he  learns  the  result  at  once,  while  the  sending 
of  a  plate  to  a  photographer  involves  a  great  loss  of  time.  A  busy 
physician  should,  however,  have  the  services  of  a  well-trained  as- 
sistant, who  does  the  tedious  work  of  developing  under  his  super- 
vision. If  within  reach,  a  learned  photographer  should  be  engaged 
for  that  purpose,  since  a  physician  seldom  learns  to  master  all  the 
minute  details  of  the  delicate  art  of  photography. 

The  plates  are  the  most  important  requirements  for  photo- 
graphic work.  For  skiagraphic  purposes  special  plates  are  gener- 
ally used.  Some  manufacturers  furnish  specially  prepared  plates 
which  are  separately  wrapped  and  sealed  in  black  and  in  yellow 
envelopes.  But  while  it  is  very  convenient  to  have  the  "  individ- 
ually wrapped  plates  "  ready  for  immediate  use,  it  must  be  remem- 
bered that  the  wrappers  affect  the  sensitized  surface,  and  conse- 
quently injure  their  keeping  qualities.  They  are  therefore  not  to 
be  recommended.  All  these  plates  are  extremely  sensitive  and 
slightly  radioactive.  They  must  therefore  be  well  guarded  against 
injury  by  too  strong  a  light  while  developing,  or  by  traces  of  dif- 
fused light  entering  the  dark  room  or  the  envelope,  lens,  or  camera. 
As  the  object  to  be  skiagraphed  must  rest  on  the  film  side,  it  is 
important  to  ascertain  before  the  exposure  which  is  the  film  side. 
In  holding  the  film  against  the  red  lantern  light  its  dull  appear- 
ance becomes  evident,  while  the  plain  glass  side  shines.  But  even 
this  kind  of  light  should  not  be  trusted  too  much;  consequently 
the  test  had  better  be  made  by  the  touch.  A  practised  finger  will 
ascertain  at  once  which  is  the  sensitive  side.  In  case  of  doubt, 
however,  the  moistened  finger  may  carefully  touch  the  corner  of 
the  plate,  which,  if  covered  by  the  film,  will  feel  sticky.  It  should 
also  not  be  forgotten  that  perspiration  of  the  hand  leaves  marks 
and  spots  on  the  plate. 

The  developing  of  the  plate  must  be  done  in  a  dark  room,  if 
possible  of  ample  size.  Moisture  as  well  as  heat  spoil  the  plate. 
It  must  not  be  situated  too  near  the  room  in  which  the  Bbntgen-ray 
apparatus  is  placed,  because  the  rays  may  penetrate  the  door  and 
even  the  walls,  thereby  influencing  the  plates  in  their  boxes. 
There  must  be  an  abundant  supply  of  water.  A  sink  about  5  inches 
deep  and  3  feet  square,  consisting  of  Avood  and  lined  with  zinc, 
should  be  placed  in  front  of  2  or  3  faucets.  A  grating,  on  which 
the  developing  trays  are  set  up,  must  be  above,  and  a  table  which 


SKIAGRAPHY  47 

serves  for  chemical  manipulation  and  the  mixing  of  developers, 
etc.,  near  by.  Shelves  For  storing  the  bottles,  which  contain  these, 
are  placed  above  this  table. 

The  dark-room  lantern  also  deserves  thorough  attention.  Ruby 
light  is  recommended  as  the  best  "  dark-room  light."  As  alluded  to 
above,  it  is  used  while  the  plates  are  taken  from  their  boxes  and 
put  into  a  photographic  envelope  or  into  a  plate  bolder,  or  during 
the  process  of  developing.  As  it  is  described  in  Chapter  X  VIII,  on 
the  Chemical  Actions  of  the  Rontgen  Rays.  rc<\  and  yellow  colours 
affect  the  sensitiveness  of  the  plate  very  much  Less  than  green, 
blue,  or  violet.  This  lack  of  sensitiveness  to  red  light  is  utilized 
in  the  process  of  handling  and  studying  a  sensitized  plate.  But 
while  being  the  least  actinic  light — that  is.  while  affecting  it  the 
least — even  red  light  produces  slight  changes  after  a  long  exposure. 
It  is  advisable  therefore  to  study  the  plates  at  a  distance  from  the 
ruby  light,  as  there  is,  in  fact,  no  light  which  is  absolutely  sale. 
As  the  source  of  light,  electricity  is  far  preferable.  But  gas  and 
kerosene  may  also  be  used. 

By  developing  the  plate — that  is,  by  producing  the  latent  image 
with  the  aid  of  a  chemical  solution,  called  developer — the  silver 
salts,  which  had  been  influenced  by  the  rays  during  exposure,  are 
reduced.  The  areas  not  affected  by  the  light  will  not  be  affected 
by  the  developer,  while  those  acted  upon  by  the  light  show  more 
or  less  opacity  in  proportion  to  the  degree  of  influence.  Thus  the 
brightest  areas  appear  the  darkest,  therefore  the  image  is  called  a 
"  negative." 

Among  the  various  developers  recommended  may  be  men- 
tioned hydrochinone,  hydrochinone-eikonogen,  and  metal-hydro- 
powder.  The  latter  seems  fit  especially  for  short  exposures.  Some 
firms  produce  these  chemicals  in  tablet  form,  which  is  rather  com- 
modious for  a  novice. 

Very  large  plates  should  be  immersed  in  water  before  the  de- 
veloper is  used.  The  strength  of  the  developer,  which  is  mixed 
with  cold  water,  should  be  moderate.  During  the  hot  weather  the 
developer  must  be  more  diluted  and  cold,  while  it  may  be  stronger 
and  warmer  (70°  F.)  during  the  cold  season.  Too  warm  and  too 
strongly  alkaline  developers  cause  stains  and  fog  on  the  plate. 

After  the  mixture  is  properly  prepared  it  is  poured  into  a 
hard-rubber  tray  and  the  plate  is  placed  in  it  with  the  film  side  up. 
The  developer  must  at  once  cover  the  plate  all  over.    If  the  plate  is 


48  THE    RONTGEN    RAYS 

rocked  then  from  side  to  side  for  about  three  minutes  the  image 
appears.  The  rocking  can  be  done  automatically  by  using  a  motor. 
Gocht  has  constructed  an  ingenious  apparatus  in  connection  with 
an  accumulator  which  answers  the  purpose  well. 

Then  the  plate  remains  in  the  solution  for  another  two  min- 
utes until  it  appears  dark  and  the  image  has  nearly  entirely  dis- 
appeared. Sometimes  it  may  last  as  long  as  twenty  minutes  until 
a  sufficient  amount  of  density  is  reached.  If  there  is  a  lack  of 
clearness,  a  few  drops  of  a  10-per-cent  solution  of  bromide  of 
potassium  should  be  added.  Thus  we  see  that  the  process  of  devel- 
oping often  requires  considerable  loss  of  time.  It  may  therefore 
well  be  undertaken  by  an  intelligent  servant.  The  plate  should  not 
be  studied  too  frequently  during  development,  and  must  not,  as 
demanded  above,  be  brought  nearer  to  the  ruby  light  than  a  dis- 
tance of  one  foot.  In  studying  it,  its  film  side  must  be  turned 
towards  the  lantern. 

If  there  should  have  been  overexposure,  the  plate  must  be 
thoroughly  washed,  and  may  then  be  finished  with  a  bromo-hydro- 
chinone  developer.  But  if  undertimed — the  details  not  being  dis- 
tinct— a  fresh  developer  must  be  used.  Then  the  plate  is  immersed 
in  a  tray  containing  water  to  which  some  sulphite  and  carbonate 
of  sodium  have  been  added,  and  is  left  in  this  solution  until  the 
details  come  out  more  clearly.  The  same  procedure  may  be 
repeated  if  the  image  does  not  appear  to  be  satisfactory. 

If  the  condition  of  the  development  harmonizes  with  that  of  the 
exposure  no  correcting  steps  are  necessary,  and  the  plate  is  simply 
taken  out  of  the  tray.  It  is  inserted  in  a  tray  which  contains 
fresh  water,  or  it  may  be  held  under  the  faucet,  a  gentle  stream  of 
water  being  permitted  to  wash  off  the  developer.  It  is  this  second 
hard-rubber  tray  which  contains  a  solution  of  hyposulphite  of 
sodium.  After  the  plate  has  remained  in  this  solution  for  about 
four  minutes  its  light  colour  will  change  into  black.  Now  the 
image  is  regarded  as  fixed,  and  the  plate  may  be  exposed  to  light 
without  being  injured. 

The  process  is  completed  by  washing  the  plate  in  running  water 
for  thirty  minutes,  and  then  setting  it  upon  a  stand. 

The  details  of  instruction  regarding  the  properties  of  various 
developers  are  best  studied  in  the  guiding  prescriptions  given  with 
the  developers  by  each  firm.  Recently  Albers-Schonberg  recom- 
mended the  so-called  "  stand  developing  "  with  glycon  as  the  best 


SKIAGRAPHY  49 

method  for  skiagraphic  work.  The  plate  is  immersed  in  the  glycon 
developer  for  fifteen  to  sixty  minutes,  being  inspected  every  ten 
minutes,  until  it  appears  satisfactory.  Then  it  is  well  washed 
and  kept  in  the  fixation  tray  for  fifteen  minutes. 

Foggy  negatives  may  sometimes  he  caused  by  a  decomposed 
developer,  or  by  one  containing  too  much  carbonate  of  sodium  or 
potassium  without  bromide.  Weak  negatives  with  distinct  details 
in  the  shadows  arc  produced  either  by  overexposure  or  by  too 
weak  a  developer. 

Overexposure  is  at  once  recognised  by  the  quick  and  simultane- 
ous appearance  of  the  image  over  the  whole  plate  and  its  lack  of 
contrast.  It  disappears  just  as  rapidly,  leaving  a  dark  veil.  The 
sensitiveness  of  the  photographic  plate  being  affected  too  long,  too 
much  detail  is  produced  in  the  shadows,  and  consequently  the  dif- 
ference between  the  highly  lighted  and  shaded  areas  is  small.  Weak- 
negatives  with  clear  shadows  indicate  underdevelopment.  Too 
strong  negatives  with  distinct  shadows  indicate  underexposure. 

Underexposure  is  recognised  by  the  slow  and  difficult  appear- 
ance of  the  image.  The  latter  is  transparent  and  shows  only 
general  outlines.  The  highly  lighted  areas  come  out  first.  There 
is  too  much  contrast  in  fact.  The  sensitiveness  of  the  photo- 
graphic plate  was  not  affected  long  enough  to  be  impressed,  there- 
fore blank  areas  are  left  which  should  have  shown  structural  de- 
tails. After  a  normal  exposure  the  various  areas  appear  in  the 
order  of  their  individual  transparency. 

If  the  plate  is  insufficiently  developed  it  may  be  strengthened 
by  a  so-called  intensifying  solution.  The  plate  may  be  immersed 
in  a  solution  tray  containing  the  following:  Water,  20  ounces; 
bichloride  of  mercury,  ammonium  chloride,  -J  ounce  each.  The 
tray  is  rocked  until  the  image  is  thoroughly  white.  After  being 
removed  from  the  solution  the  plate  is  washed  for  thirty  minutes, 
and  then  bathed  in  ammonium  chloride  (20  ounces  of  water  con- 
taining \  ounce  of  the  ammonium  chloride).  Then  it  is  washed 
over  again,  and  finally  immersed  in  a  solution  of  ammonia  (1 
drachm  of  ammonia  water  to  8  ounces  of  fresh  water)  till  the  whit- 
ish appearance  has  changed  into  dark.  Another  washing  for  five 
minutes  may  finish  the  process,  which  is  often  overdone,  the  skia- 
graph then  becoming  transparent.  In  such  an  event  the  density 
may  be  reduced  again  by  placing  the  plate  in  a  reducing  solution, 
after  it  is  soaked  in  water  for  about  half  an  hour.  A  useful  solu- 
5 


50  THE    EONTGEN    RAYS 

tion  of  this  kind  consists  of  10  ounces  of  fresh  water  containing 
100  grains  of  ammonia-persulphate. 

The  proper  tints  of  the  light  and  dark  shades  are  obtained  by 
producing  a  positive  print.  Some  of  the  finer  details  of  the  plate 
are  lost  in  this  process.  The  positive  can  be  made  on  glass,  cellu- 
loid, or  paper  coated  with  an  emulsion  of  albumin,  collodion, 
or  gelatin  in  which  silver  chloride  is  incorporated.  If  put  on 
paper,  it  is  customary  to  simply  call  the  positive  a  print.  Paper 
of  this  kind,  called  printing  paper,  is  placed  in  a  printing  frame 
with  its  face  on  the  photographic  plate  and  is  pressed  towards 
it  by  a  spring  clamp  in  the  back  of  the  frame.  The  glass  in 
the  frame  must  then  be  reached  by  the  snn  at  a  right  angle. 
The  time  required  for  printing  depends  upon  the  time  of  the  day 
and  the  year,  and  the  density  of  the  image.  If  exposed  to  bright 
sunlight  the  printing  may  not  last  longer  than  five  minutes.  It 
must  be  continued  until  there  is  a  tone  which  is  slightly  darker 
than  the  one  expected  for  the  final  print.  The  fixing  of  the  print 
is  done  virtually  in  the  same  manner  as  that  of  the  plate.  The 
proper  formulas  are  always  sold  with  the  paper.  After  being 
taken  out  from  the  fixing  bath,  the  print  is  washed  and  fixed. 
Finally  it  is  washed  in  running  water  for  about  an  hour.  In  a 
good  skiagraphic  print  the  dense  areas  are  shown  in  a  dark  tone. 

Stereofluoroscopy  and  Stereoskiagraphy. — A  skiagraph  being  a 
map-like  reproduction  of  tissues  naturally  does  not  show  any 
depth  or  perspective.  So  it  neither  gives  any  information  on 
the  dimensions  in  the  depth  nor  on  the  relations  of  the  individual 
bones  to  each  other.  Stereofluoroscopy  was  introduced  by  Elihu 
Thomson  by  switching  the  secondary  discharge  of  the  induc- 
tion coil  from  one  Eontgen  tube  to  another  by  a  revolving  switch 
arrangement. 

The  distance  between  the  tubes  and  their  relation  to  the 
screen  must  be  so  arranged  that  no  distortion  of  the  shadows  oc- 
curs. By  means  of  this  mechanism  the  space  relations  can  be  esti- 
mated so  that  foreign  bodies  can  be  located.  The  reduction  of 
bone  splinters  may  also  be  controlled  in  this  manner.  Weigel  and 
Johnson  constructed  excellent  modifications  of  the  Wheatstone 
stereoscope.  Weigel's  instrument  permits  of  varying  the  intensity 
of  the  light  as  the  distance  of  the  lamp  is  shifted  from  the  negative. 

With  the  methodical  introduction  of  stereoscopy  into  Eont- 
gen practice  by  Hildebrand  and  Kuemmell  new  information  was 


SKIAGRAPHY 


51 


obtained.  The  principle  of  ordinary  stereoscopic  photography  ••(in- 
sists, like  in  stereofluoroscopy,  in  a  system  by  which  two  exposures 
of  the  same  objed  can  be  made  iii  two  different  positions,  [f  the 
views  obtained  from  these  positions  are  combined  by  a  reflecting 
or  refracting  apparatus,  the  parts  stand  out  in  their  natural  rela- 
tionship. 

In  order  to  he  able  to  take  two  skiagraphs  of  the  same  area, 
the   arrangement   of   the   plates   must   he   such  that  they  ean  be 


TmifiiiiTiiri'iinl 


Wi!/i;im\\\\\\\wm 


Fig.  32. — Apparatus  of  Hildebrand. 


changed  without  altering  it.  The  plate  must  then  be  marked  for 
registration.  The  modus  operandi  consists  in  placing  the  patient 
upon  a  table  or  couch  to  the  sides  of  which  two  uprights  and  a 
cross-piece  are  fastened.  The  latter  is  provided  with  a  clip  which 
holds  the  tube  so  that  it  can  slide  along  it  in  either  direction. 
Over  a  scmare  frame  placed  in  the  opening  which  is  cut  through 
the  centre  of  the  examining  table  a  sheet  of  vellum  is  stretched. 
The  distance  of  the  tube  from  the  area  to  be  examined  should 


52 


THE    KONTGEN    EAYS 


amount  to  about  15  inches,  while  that  of  the  two  positions  of  the 
anode  should  be  3.  Across  the  vellum  and  parallel  to  the  gradu- 
ated cross-bar  two  thin  wires  are  also  strained  and  graduated.    The 


Fig.    33.— Fracture    of    Femoral   Diapiiysis,  showing   Angular  Deformity 
(Anterior  View).     (Compare  Fig.  34) 

centre  of  the  skiagraphic  plate  must  be  vertical  underneath  the 
vellum.  After  the  skiagraph  is  made,  the  plate,  without  altering 
the  position  of  the  patient,  is  inserted  and  the  clip  run  back  till  it 
makes  a  halt  at  the  other  sliding  piece.    The  same  tube  is  used  and 


SKIAGRAPHY 


53 


the  same  length  of  exposure  given.  Hildebrand  (Fig.  32)  con- 
structed a  stereoscope  which  permits  skiagraphing  on  one  plate. 
One-half  of  the  glass  plate  is  covered  with  a  thin  plate  of  Lead, 
which  does  not  permit  penetration  by  the  rays.  After  the  exposure 
is  completed  the  photo- 
graphic plate  is  si i i  fled 
forward,  and  its  exposed 
area  is  covered  with  the 
lead  plate.  Then  the 
non-exposed  area  is  ir- 
radiated. By  adding  a 
sliding  mechanism  Al- 
bers  Schonberg  has 
modified  his  compres- 
sion diaphragm  in  such 
a  manner  that  it  can 
be  utilized  for  stereo- 
scopic skiagraphy. 

Routine,  however, 
often  enables  the  sur- 
geon to  locate  a  bullet, 
as  in  the  case  illus- 
trated by  Fig.  16,  or 
bone  fragments,  as  in 
the  cases  illustrated  by 
Figs.  33  and  34.  They 
show  the  overlapping  of 
the  fragments  of  the  fe- 
mur in  a  boy  of  seven 
years  seven  weeks  after 
the  injury.  The  fact 
that  the  end  of  the  up- 
per    fragment     appears 

less  translucent  than  the  lower  indicates  that  the  latter  was  near 
the  plate — that,  in  other  words,  it  was  situated  at  the  outer  side 
of  the  thigh.  As  to  details  of  history,  see  Chapter  XVI.  Fig.  35 
represents  a  counterpart. 

In  both  instances  bloodless  re-fracture  was  successfully  done. 

Foreign  Bodies. — While  it  is  easy,  as  a  rule,  to  recognise  for- 
eign bodies  by  the  screen  as  well  as  by  skiagraphic  exposure,  the 


Fig.  84. — Fracture  of  Femoral  Diaphysis, 
showing  Overlapping  of  Fragments  (Dor- 
sal View).     (Compare  Pig.  33.) 


54 


THE    BONTGEN    RAYS 


determination  of  their  position  is  sometimes  very  difficult.  For 
locating  the  position  of  foreign  bodies  more  than  a  hundred  meth- 
ods are  advised.  Most  of  them  are  ingenious  hut  somewhat  com- 
plicated for  practical  use.  They  are  all  based  upon  similar  prin- 
ciples. The  wire  letters  used  by  the  author  for  registration  may 
serve  as  landmarks  in  a  simple  manner  by  being  attached  by 
means  of  adhesive  plaster  to  the  region  of  the  body  to  be  irradiated, 
after  it  has  first  been  marked  with  the  skiagraphic  pencil.     Wire 


Fig.   35. — Fracture  of  the  Middle  of  the  Femur,  showing  Juxtaposition, 
Seven  Weeks  after  the  Injury,  in  a  Boy  of  Seven  Years. 


letters  may  also  be  placed  on  the  plate  just  below  a  wound  or  a 
scar,  indicating  the  entrance  of  a  foreign  body.  If  there  is  a 
wound  sinus,  a  probe  may  be  introduced  as  far  as  it  is  possible. 
Thus  the  extent  of  abscess  cavities  may  be  ascertained  (Fig.  55). 
Fig.  36  illustrates  the  arm  of  a  man  of  twenty-eight  years 
who  was  shot  three  years  before  the  skiagraph  was  taken,  and  who 
since  had  suffered  from  the  symptoms  of  pressure  on  the  median 
nerve.  Two  exposures  were  made,  one  on  the  flexor  area,  another 
on  the  extensor  side.     In  proportion  to  an  angle  of  90  degrees 


SKIAGRAPHY 


55 


four  metallic  letters  were  attached  at  equal  intervals  to  the  surface 

of  the  arm  by  adhesive  plaster,  A  illustrating  the  anterior,  P  the 
posterior,  /  the  interior,  and  E  the  exterior  aspect,  as  shown  by 

the  skiagraph.  The  point  of  recognisable  attachmenl  was  made  at 
the  integument  before  by  marking  them  with  nil  rate  of  silver. 
The  comparison  of  the  various  diameters  revealed  the  location  of 
the  bullet,  which  was 
extracted  under  local 
anaesthesia.  The  bul- 
let, on  account  of  hav- 
ing struck  the  bone, 
had  assumed  a  flat- 
tened shape. 

For  foreign  bodies 
which  can  be  seen 
best  in  one  direction 
only,  as,  for  instance, 
needles  buried  in  the 
foot  or  in  the  hand, 
Shenton  (Guy's  Hos- 
pital, London)  sug- 
gested the  following 
method : 

"The  surface  of  the 
palm  of  the  hand,  for 
example,  is  held  in  di- 
rect contact  with  the 
screen,  seeing  that  the 
screen  and  anode  in 
the  tube  are  as  nearly 
parallel  as  possible. 
When  the  needle  and 
bones  are  seen  dis- 
tinctly, sway  the  screen  and  hand  from  side  to  side  and  note  the 
change  in  relation  of  bones  and  needle.  It  is  evident  that  the 
image  of  whichever  is  farthest  from  you  and  from  the  surface  of 
the  screen  will  move  the  faster.  If  the  needle  moves  across  the 
bone,  its  position  is  deeper  than  the  bone ;  if  the  bone  moves  across 
the  needle,  the  latter's  position  must  be  between  the  surface  and 
the  bone. 


Fig.  36.— Localization   of  Bullet  in  the  Arm 
by  Wire  Letters. 


56  THE    RONTGEN    EAYS 

"Should  the  needle  appear  stationary,  place  a  pointer  against 
the  image  on  the  screen  and  ascertain  whether  it  moved  a  little  or 
not  at  all.  Verify  these  results  by  reversing  the  hand  and  repeat- 
ing the  manoeuvres.  A  little  practice  enables  one  to  give  as  near 
an  estimate  of  the  needle's  real  depth  as  any  surgeon  could  require, 
and  such  suggestions  as  '  just  beneath  the  skin  of  the  palm/ 
'  lower  and  between  bones/  'upper  end  |  of  an  inch  between 
the  skin  of  the  back  of  the  hand '  are  in  my  experience  sufficient 
for  any  operator. 

"  The  needle's  depth  being  ascertained,  it  only  remains  to  find 
its  position  in  the  horizontal  planes — a  task  which  represents  few 
difficulties.  When  found,  this  position  should  be  marked  upon  the 
skin.  The  advantages  of  this  method  are  its  rapidity  of  perform- 
ance, the  process  taking  but  a  few  seconds,  and  the  economy  of  the 
material  both  photographic  and  electrical. 

"  For  localization  in  other  parts  of  the  body  and  for  photo- 
graphically recording  results  I  have  constructed  an  instrument 
which  in  principle  is  the  same  as  the  method  just  described,  save 
that  the  tube  is  swayed  while  the  part  viewed  is  held  in  position  by 
bands  and  tension  springs.  The  tube  is  moved  by  the  observer 
from  his  side  of  the  screen,  the  distance  it  travels  being  regulated 
by  sliding  steps.  A  fine  vertical  wire  is  stretched  in  the  centre 
of,  and  in  contact  with,  the  screen.  The  image  of  the  foreign  body 
is  to  correspond  with  this  line  from  the  extreme  right  to  the 
extreme  left ;  the  image  of  the  foreign  body  on  the  screen  is  seen  to 
pass  from  left  to  right.  Its  relative  rate  of  travelling  compared 
with  the  same  portion  of  bone  is  noted  as  before. 

"  For  accurate  measurements  the  true  position  assumed  by  the 
foreign  body  is  marked  by  a  pencil  on  a  celluloid  film  in  contact 
with  the  screen.  This  measurement  being  secured,  the  distance 
the  tube  travels,  and  the  distance  from  the  midpoint  of  the  line  ad- 
joining the  two  extreme  positions  of  the  tube,  must  be  ascer- 
tained. A  simple  rule  of  three  will  now  give  the  distance  of  the 
object  sought  from  the  screen." 

For  locating  foreign  bodies  in  the  skull,  the  wire  letters  rec- 
ommended above  may  also  be  used  by  being  fastened  to  a  wire 
head-band  wound  around  the  temples.  Then  the  intervals  be- 
tween the  individual  letters  must  be  measured.  The  same  pro- 
cedure can  be  carried  out  on  the  extremities  by  winding  the  wires 
around  the  limb  and  also  fixing  them  at  the  plate.  This  principle 
may  also  be  utilized  on  other  regions  of  the  body. 


SKIAGRAPHY  57 

It  must  furthermore  be  remembered  thai  the  size  of  the  foreign 
bodies  varies  with  their  distance  from  the  tube.  In  the  case  of 
oblong  bodies  great  errors  as  to  the  exact  size  may  be  made  if  a 
second  exposure  in  a  different  projection  plane  is  omitted.  Early 
in  the  Rontgen  era  the  author  was  not  a  little  surprised  in  the  case 
of  a  seamstress  in  whose  palm  a  needle  fragment  had  entered  in  a 
perpendicular  direction.  The  plate,  while  indicating  the  presence 
of  the  needle  distinctly,  created  the  impression  that  the  fragment 
was  only  2  millimetres  long.  When  extracted,  its  length  was  found 
to  be  more  than  an  inch.  The  rays  had  reached  the  hand  in  a  per- 
pendicular direction,  so  that  the  circumference  of  the  fragment 
was  reproduced  rather  than  the  length.  A  side  view,  of  course, 
would  have  cleared  up  the  error  at  once.  In  fractures  exposures 
in  different  projection  planes  are  almost  a  necessity. 


CHAPTEK    V 
EXAMINATION  OF  THE  PATIENT 

The  Technique  of  Examination. — For  fluoroscopic  as  well  as 
for  skiagraphic  examination  the  area  to  be  studied  must  be  freed 
from  clothing.  It  is  true  that  a  good  tube  permits  irradiating, 
even  through  an  overcoat,  but  small  details  become  lost.  So  the 
shadow  of  a  button  or  a  buckle  may  just  cover  a  region  of  special 
importance.  Dressings  are,  of  course,  best  removed  if  structural 
details  are  simply  wanted,  but  if  the  position  of  the  fragments  in 
fractures  is  to  be  ascertained,  they  must  not  be  removed  during 
examination.  It  is  desirable  therefore  to  choose  such  dressing 
material  which  is  translucent,  like  gauze.  For  fractures  the  plaster 
of  Paris  is  the  best  immobilizing  agent,  because  it  permits  of  a  suf- 
ficient amount  of  penetration  as  to  allow  recognition  of  the  rela- 
tions of  the  fragments.  It  does  not  impair  the  judgment  on  ac- 
count of  its  regularity,  while  wooden  splints  may  veil  important 
areas.  Adhesive  plaster,  iodoform,  and  rubber  drains  cast  dense 
shadows. 

Fluoroscopy  may  be  done  while  the  patient  stands  before  the 
examiner,  who  is  seated  in  a  chair.  The  head  is  fluoroscoped  best 
while  the  patient  is  seated  in  a  chair.  In  fluoroscopy  of  the  lower 
extremities  the  patient  may  be  seated  in  a  chair  placed  on  a  table, 
so  that  the  soles  of  his  feet  rest  on  the  latter.  As  a  rule,  tubes  of 
medium  hardness  are  most  useful  in  fluoroscopy. 

In  order  to  study  any  region  of  the  body  with  leisure,  and  to 
observe  its  structural  details,  a  skiagraphic  exposure  is  necessary. 
In  most  instances  the  patient  is  skiagraphed  best  in  the  recumbent 
position.  This  may  be  done  on  one  of  the  tables  which  are  pro- 
vided with  a  box  for  receiving  the  photographic  plate  (Fig.  37). 
The  patient  may  also  be  placed  on  the  carpeted  floor.  This  sim- 
ple arrangement  offers  the  advantage  of  a  wide  operating  field 
around  the  patient.  The  extremities  can  be  placed  in  any  position 
58 


EXAMINATION    OF    THE    PATIENT 


59 


desired,  and  blocks,  .sand-bags,  large  books,  etc,  may  be  used  to 
surround  and  immobilize  the  area  to  be  skiagraphed.  In  the  case 
of  nervous  children  there  is  no  fear  of  their  falling  from  the 
table. 

The  tube-holder  is  placed  best  between  the  Ruhmkorff  coil  and 
the  patient.     The  wires  connecting  the  secondary  terminals  of  the 


Fig.  37.— Queen's  Examining  Table. 


Euhmkorff  coil  with  the  tube  may  be  loosely  hooked  in  the  ter- 
minals. 

These  must  be  kept  separate  in  order  to  avoid  shocks.  Their 
calibre  should  be  very  small,  but  they  must  be  surrounded  by  a 
thick  layer  of  insulating  material. 

The  anticathode  should  be  connected  with  the  anode,  and  the 
anode  with  the  positive  electrode  of  the  Ruhmkorff  apparatus, 
while  the  cathode  is  to  be  connected  with  the  negative  electrode 
of  the  apparatus.  The  tube-holder  must  permit  the  tube  to  be 
moved  in  any  position  desired.    A  false  direction  of  the  current  is 


60  THE    KONTGEN    RAYS 

indicated  by  the  appearance  of  a  marked  shadow  originating  from 
the  anticathode  and  the  formation  of  blue  light. 

The  distance  of  the  tube  is  also  a  matter  of  great  importance. 
Various  distances  produce  various  relations.  The  smaller  the 
distance  is  between  the  tube  and  the  plate,  the  larger  the  silhouette 
of  the  irradiated  part  appears.  On  the  other  hand,  the  smaller  the 
silhouette  is,  the  more  correct  the  proportions  of  the  tissues  appear. 

Under  ordinary  circumstances  the  tube  should  be  as  near  the 
object  to  be  skiagraphed  as  possible  (6  inches),  in  order  to  make 
the  exposure  short.  The  effect  of  irradiation  is  reduced  in  propor- 
tion to  the  square  of  the  distance  between  plate  and  target.  As  an 
average  it  may  be  assumed  that  an  equally  good  skiagraph  of  the 
human  hand  is  made  when  the  distance  is  6  inches,  the  exposure 
lasting  half  a  minute,  as  when  the  distance  amounts  to  12  inches, 
the  exposure  lasting  a  whole  minute.  It  is  not  possible  to  set  down 
any  definite  ratio,  because  the  duration  of  the  exposure  is  depend- 
ent upon  the  coil  as  well  as  upon  the  kind  of  the  tube,  the  thick- 
ness of  the  irradiated  areas,  the  distance  of  the  tube,  and  the  nature 
of  the  plate. 

If  a  good  tube  is  used  in  connection  with  a  Wehnelt  inter- 
rupter, it  may  be  expected  that  twenty  seconds'  exposure  suffices  for 
the  reproduction  of  an  adult's  hand.  The  forearm  requires  a 
little  less  than  a  minute,  and  the  elbow,  the  arm,  and  the  foot  one 
to  one  and  a  half  minutes.  The  leg,  the  knee,  and  the  thorax  take 
about  two,  the  skull  two  to  three,  and  the  pelvis  about  three  to 
four  minutes. 

Position  of  Patient. — The  position  during  irradiation  is  of  im 
portance.  The  nearer  the  area  to  be  irradiated  is  to  the  tube,  the 
clearer  and  more  promptly  appears  the  image.  The  fact  must  not 
be  lost  sight  of,  however,  that  the  nearer  the  tube  is,  the  greater  is 
the  danger  of  burning  the  patient;  but  this,  as  will  be  seen  later, 
need  be  considered  in  repeated  exposures  only. 

The  position  of  the  special  part  to  be  skiagraphed  is  also  of 
great  importance.  It  is  difficult  to  lay  down  any  definite  rules  for 
this,  since  each  case  demands  a  special  perspective.  In  general, 
however,  the  following  directions  may  be  adhered  to : 

The  skull  is  examined  either  in  the  recumbent  position  or  while 
the  patient  is  seated  on  a  chair.  An  antero-posterior  as  well  as  a 
lateral  view  are  generally  necessary.      (Fig.  28.) 

The  neck  is  best  shown  in  the  lateral  direction. 


EXAMINATION    OF   THE    PATIENT  01 

The  forearm  is  best  seen  in  supination,  although  this  position 
is  by  no  means  the  most  comfortable  for  the  patient.  In  injuries 
or  ankylosis  of  the  elbows  special  supporting  devices  must  be 
sought.  The  olecranon  and  the  external  condyle  serve  as  land- 
marks. The  arm  and  the  thigh  can  be  taken  in  any  position. 
The  humero-ulnar  joint  is  best  irradiated  from  the  flexor  to  the 
extensor  side.  The  hand  is  usually  traversed  from  the  dorsum  to 
the  palm. 

The  foot,  from  the  toes  up  to  the  upper  third  of  the  meta- 
tarsus, is  best  skiagraphed  in  the  direction  of  the  dorsum  towards 
the  sole.  This  is  done  while  the  patient  is  seated  in  a  chair,  the 
sole  of  his  foot  resting  on  the  plate.  Farther  back  the  first  and 
third  cuneiform  bones  and  the  scaphoid  present  an  obstacle,  so  that 
it  is  advisable  to  irradiate  these  portions  of  the  foot  transversely 
by  having  its  outer  surface  resting  on  the  plate.  By  this  proce- 
dure the  isolated  shadows  of  the  astragalus,  the  caleaneum,  the 
cuboid,  the  scaphoid,  and  the  fourth  and  fifth  metatarsal  bones  can 
be  represented.      (Fig.  24.) 

The  knee-joint  is  reproduced  best  by  resting  the  external  con- 
dyle on  the  plate.  The  leg  should  be  skiagraphed  while  its  exter- 
nal surface  is  placed  on  the  skiagraphic  plate,  the  knee  being  flexed 
and  the  thigh  rotated  outward.  The  lower  margin  of  the  patella 
serves  as  a  landmark.  The  hip-joint  is  preferably  taken  by  turn- 
ing the  patient  from  his  recumbent  position  inwardly,  so  that  the 
anterior  axis  of  the  thigh  forms  an  angle  of  from  30  to  40  degrees 
with  the  underlying  plate.  The  opposite  hip  is  elevated  and  sup- 
ported accordingly. 

The  area  to  be  skiagraphed  must  be  brought  as  near  the  plate 
as  possible.  Exposures  for  special  purposes  require  special  appli- 
ances. In  skiagraphing  gall-stones,  for  instance,  pillows  must  be 
placed  under  the  clavicles.  Thus  an  elevation  is  produced  permit- 
ting the  protrusion  of  the  gall-bladder,  which  is  then  brought 
nearer  to  the  plate.  The  approximation  is  increased  by  turning  the 
body  slightly  to  the  right  and  raising  and  supporting  the  left  side 
accordingly.      (Fig.  74.) 

As  the  patient  has  to  assume  the  abdominal  position,  a  land- 
mark indicating  the  position  of  the  gall-bladder  must  be  made 
either  with  nitrate  of  silver  or  with  a  special  skiagraphic  pencil  on 
his  back  in  order  to  secure  the  proper  focus.  In  this  way  it  will 
be  possible  to  direct  the  rays  vertically  on  the  marked  area. 


62  THE    RONTGEN    HAYS 

Another  point  of  importance  is  that  the  rays  should  traverse 
the  abdomen  in  a  slightly  lateral  direction,  so  that  the  dense  tissue 
of  the  liver  is  not  permeated  in  its  whole  diameter.  The  focus 
line  may,  in  other  words,  form  an  angle  of  about  70  degrees  with 
the  dorsum.  Thus  some  of  the  rays  reach  the  calculi  before  they  are 
absorbed  by  the  compact  liver  tissue.  The  disadvantage  of  oblique 
irradiation  is  that  biliary  calculi  appear  somewhat  larger  than 
their  natural  size.  When  a  protrusion,  palpable  in  the  region  of 
the  gall-bladder,  indicates  an  enlarged  gall-bladder,  direct  irradia- 
tion should  be  attempted,  the  shadow  of  the  liver  not  obscuring 
it  then.  In  such  cases,  however,  the  diagnosis  of  cholelithiasis  can 
as  a  rule  be  made  without  skiagraphic  examination. 

As  to  other  special  arrangements,  see  Chapters  VIII  and  IX  on 
the  Thorax,  the  Abdomen,  and  the  Spinal  Column. 

Absolute  rest  is  the  condition  sine  qua  non  for  a  successful 
exposure.  Involuntary  movements  like  those  caused  by  the  res- 
piration cannot  be  avoided.  Sometimes  respiration  may  be  sus- 
pended for  half  a  minute,  so  that  with  a  short  exposure  a  skia- 
graph is  obtained.  Nervous  twitchings  are  combated  best  if  the 
patient  rests  as  comfortably  as  possible.  The  trunk  must  be  sup- 
ported by  heavy  pillows  and  the  extremities  by  sand-bags.  The 
best  immobilization,  however,  is  obtained  by  compressing  the  irra- 
diated area  by  the  diaphragm.  Intelligent  mothers  generally  suc- 
ceed in  lulling  their  babies  to  sleep.  By  manipulating  the  appara- 
tus with  a  low  current  first,  and  then  increasing  it  gradually,  its 
monotonous  noise  sometimes  acts  as  a  lullaby.  Adhesive-plaster 
strips  or  gauze  bandages  are  also  useful  for  immobilization.  Straps 
may  exceptionally  be  used.  Anaesthesia  for  the  purpose  of  keeping 
patients  quiet  should  be  resorted  to  only  under  the  most  pressing 
necessity. 

Density  of  Objects. — The  degree  of  density  is,  of  course,  a  de- 
termining factor  for  the  distinctness  of  the  skiagraph.  It  is  well 
known  that  the  higher  the  atomic  weight  of  any  element  is,  the 
more  energetic  the  absorption  of  the  rays  will  be.  The  atomic 
weight  of  those  elements  with  which  we  have  mainly  to  deal  in 
using  the  Eontgen  method  is  as  follows:  Hydrogen,  1;  carbon,  12; 
nitrogen,  14;  oxygen,  16;  fluorine,  19;  sodium,  23;  magnesium, 
24;  phosphorus,  31;  sulphur,  31;  chlorine,  35.5;  potassium,  39; 
calcium,  40;  iron,  56. 

The  inorganic  substances  of  the  body,  such  as  salts  of  lime  in 


EXAMINATION    OF    THE    PATIENT  63 

the  bones,  absorb  more  light  than  the  surrounding  soft  tissues; 
consequently  they  are  but  slightly  permeable  by  the  rays.  The 
more  lime  salts  the  bone  contains,  therefore,  the  less  permeability 
exists,  and  the  more  distinct  the  shadow  will  be  on  the  photo- 
graphic plate.  Thus  compact  bone  tissue  shows  a  very  much  more 
distinct  image  than  do  the  medullary  or  spongy  parts.  The  spe- 
cial structures  of  the  different  bones  can  be  recognised  so  well,  in 
fact,  that  the  finest  details  of  the  structure  of  osseous  tissue  can  be 
represented.  This  offers  a  splendid  opportunity  for  studying  the 
transformation  of  bone  tissue,  which  was  formerly  a  sealed  book. 

The  organic  tissues  of  the  human  body  show  permeability  of  a 
medium  degree.  The  degree  of  translucency  of  the  muscular  layer 
of  the  heart  or  of  a  hand  or  foot  corresponds  with  that  of  a  liver 
or  kidney  of  the  same  thickness.  The  tissues  of  the  nerves  and 
blood-vessels  are  somewhat  less  permeable.  This  similarity  of  the 
degree  of  transparency  explains  why  in  skiagraphs  "of  soft  parts 
no  special  variety  of  tissue,  such  as  muscles,  tendons,  ligaments, 
nerves,  or  vessels  is  individually  marked.  With  ve"ry  soft  tubes, 
and  by  carefully  developing  the  skiagraphic  plates,  however,  hya- 
line cartilage  can  be  distinctly,  and  tendons  and  ligaments  faintly 
differentiated.  The  greater  distinctness  of  some  portions  is  there- 
fore not  due  to  the  character  of  the  individual  tissue,  but  to  the 
greater  thickness  of  the  irradiated  mass. 

Since  cartilage  is  permeated  by  the  rays,  as  a  rule,  normal 
joints  show  enlarged.  The  epiphyseal  lines  appear  well  marked. 
In  children  the  line  of  ossification  is  translucent,  and  this  has 
often  given  rise  to  false  interpretation,  especially  to  an  incor- 
rect diagnosis  of  fracture.  The  infantile  vertebras  appear  widely 
separated  from  each  other,  thus  giving  the  erroneous  impression 
that  there  is  a  pathological  hiatus. 

It  is  evident  therefore  that  the  nature  of  the  chemical  composi- 
tion of  the  organic  tissues  must  he  well  known  in  order  to  appre- 
ciate the  changes  brought  on  by  the  various  stages  of  development 
as  well  as  by  pathological  changes.  As  to  details  reference  is  made 
to  Chapters  XIII  and  XIV. 


SECTION    II 

REG  ION AR  Y  PART 


CHAPTER    VI 
THE  HEAD 

Head. — The  examination  of  the  head  offers  great  technical  diffi- 
culties which  are  not  only  produced  by  the  peculiar  anatomic  condi- 
tions, but  also  by  the  fact  that  the  motions  of  respiration  and  of  the 
heart  are  communicated  to  it,  thus  interfering  with  absolute  quiet. 

Intracranial  representation  is  especially  difficult  on  account 
of  the  diffusion  of  the  rays.  With  the  screen  the  head  can  be 
examined  while  the  patient  is  seated  on  a  chair.  Skiagraphy 
may  be  done  in  the  same  position,  but  it  is  preferable  to  have 
the  patient  on  a  table.  The  facial  portion  of  the  skull  can  be 
clearly  outlined,  but  the  larger  portion  of  the  cranium  is  dark- 
ened by  the  shadow  of  the  brain,  as  well  as  by  that  of  the  opposite 
cranial  wall.  To  study  the  relations  properly  a  sagittal  and  a 
frontal  exposure  must  be  made.  If  the  left  side  of  the  head  rests 
on  the  plate,  the  irradiation  taking  place  from  the  right,  the  soft 
tissues  and  the  galea  aponeurotica  are  recognised  as  a  light  shadow. 
The  soft  tissues  of  the  nose,  lips,  and  chin  appear  conspicuously. 

Of  the  bony  parts,  the  external  occipital  protuberance,  also  the 
orbital,  nasal,  and  sphenoid  cavities  are  easily  recognised.  In  the 
centre  of  the  temporal  bone  the  light  shadow  of  the  external  audi- 
tory canal  is  seen.  Below  the  latter  the  small  cavities  of  the  mas- 
toid process  may  be  perceived;  the  zygoma  is  also  quite  distinct. 
The  nasal  bones  and  the  superior  maxilla  showing  the  quadrangu- 
lar shadow  of  the  antrum  of  Highmore,  can  especially  well  be  rep- 
resented.     (Fig.  28.) 

The  nasal  process,  the  hard  palate,  the  alveolar  process,  and 
its  cells  and  teeth,  the  inferior  maxilla,  showing  its  mental  fora- 
64 


THE    HEAD 


65 


men,  the  protuberance,  the  external  oblique  line,  the  angle  with  its 
two  processes,  can  be  well  demonstrated.  With  these  osseoue  struc- 
tures the  shadow  of  the  tongue  and  the  velum  palati  contrast  well. 


The  motions  of  the  velum  palati  and  of  the  tongue  can  be  easily 
studied  by  the  fluoroscope.     Schneier  has  considerably  increased 
our  knowledge  on  the  physiology  of  the  phonation  by  his  fluoro- 
scopic studies  in  this  connection. 
G 


66 


THE    RONTGEN    KAYS 


By  placing  the  patient's  face  on  the  plate,  and  the  tube  behind 
it,  the  margins  of  the  orbit,  the  frontal  and  nasal  cavities,  and  the 
nasal  bones  seem  well  outlined. 

Tumours  of  the  facial  bones  are  representable,  while  intra- 
cranial growths  show  under  extraordinary  circumstances  only.  If 
containing  calcareous  matter  they  appear  marked,  of  course. 

In  a  girl  of  two  years  (Fig.  278)  the  connection  of  glioma 
with  the  orbital  wall  as  well  as  the  proliferation  into  the  optic 
foramen  could  be  proved  by  skiagraphy.  Thus  the  technical  diffi- 
culties of  the  operation  were 
illustrated  beforehand,  which 
is  important  in  a  case  the 
prognosis  of  which  is  so  ex- 
tremely grave.  As  to  other 
eases  of  osteosarcoma  of  face, 
see  Chapter  XIV  on  Neo- 
plasms. 

Peculiarities  in  Infants. — 
In  the  infantile  skull  the  de- 
tails can  be  represented  much 
better  (Fig.  38).  Even  the 
interior  of  the  ear  (cochlea 
and  semicircular  canals)  can 
be  shown. 

Fig.  143  also  shows  the  in- 
ternal structures  of  the  skull 
distinctly.       It    is    the    skia- 
graphic  reproduction  of  the  case  of  rudimentary  ear,  illustrated 
by  Fig.  142.     The  question  whether  there  was  an  auditory  canal 
was  settled  by  the  skiagraph  in  the  affirmative. 

Fig.  39  represents  a  boy  of  five  weeks  who  shows  a  spherical, 
non-pulsating  tumour,  of  the  size  of  an  orange,  projecting  from 
the  naso-frontal  region,  and  sinking  downward  to  the  alas  nasi. 
At  birth  the  tumour  was  a  trifle  smaller.  The  walls  of  the 
growth  were  thin,  and  the  integument  appeared  normal.  Con- 
tractions of  the  tumour  were  observed,  especially  while  the  child 
was  crying.  During  sleep  the  tumour  seemed  somewhat  smaller. 
There  was  exquisite  fluctuation,  and  the  contents  could  be  pressed 
almost  entirely  into  the  skull,  which  did  not  cause  any  reaction. 
Pulsation  of  the  brain  could  not  be  detected,  nor  could  the  bor- 


Fig.  39. — Hydromeningocele. 


THE    HEAD 


67 


der  of  the  cranial  opening  be  felt  distinctly.  In  view  of  these 
facts,  especially  of  the  inability  to  palpate  a  solid  mass  with  cer- 
tainty, a  meningocele  was  suggested. 

The  Rontgen  rays,  however,  modified  the  diagnosis.     The  skia- 


Fig.  40. — Nasofrontal  Hydromeningocele. 


graph,  Fig.  40,  showed  behind  the  light  shade,  representing  the 
fluid,  a  dark  one,  which  had  to  be  interpreted  as  a  solid  mass,  con- 
fined to  the  area  of  the  large  triangular  bony  opening.    That  this 


68  THE    RONTGEN    RAYS 

was  cerebral  substance  was  verified  by  tbe  subsequent  operation. 
The  skiagraph  showed  that  the  nasal  bone  was  shifted  downward, 
so  that  an  interspace  of  the  width  of  a  man's  thumb  was  left 
between  it  and  the  frontal  bone.  After  a  constriction  of  the  base 
of  the  tumour  had  been  made,  for  the  purpose  of  ascertaining 
whether  cutting  off  circulation  and  pressing  upon  the  contents 
would  produce  any  reaction,  a  prophylactic  silk  suture  was  con- 
ducted around  the  whole  circumference  of  the  tumour  at  its  base, 
in  order  to  be  able  to  control  any  excessive  haemorrhage  by  quickly 
pulling  together  the  suture  ends.  An  elliptic  flap  was  then  dis- 
sected from  the  centre  of  the  tumour  and  the  cavity  opened  lat- 
erally. After  about  a  tablespoonful  of  normal  cerebro-spinal  fluid 
had  escaped,  further  exposure  of  the  sac  revealed  its  lining,  which 
consisted  of  dura  mater  partially  protecting  degenerated  cerebral 
substance.  Near  the  base,  according  to  the  darker  shadow  of  the 
skiagraph,  cerebral  substance,  covered  by  dark-red,  velvety,  succu- 
lent, and  easily  bleeding  tissue,  protruded.  After  severing  the  pro- 
truding portion  from  its  lateral  connections,  which  were  thinly 
spread  over  the  walls,  it  was  possible  to  reduce  it  into  the  cranial 
cavity.  Two-thirds  of  the  sac  were  now  removed,  and  the  remain- 
ing stump  was  freed  from  the  frontal  bone,  including  the  perios- 
teum, until  apposition  without  tension  could  be  obtained.  The 
edges  were  then  united  with  thin  catgut,  and  supported  by  an- 
other row  consisting  of  overlapping  soft  tissues;  finally,  the  skin 
edges  were  united  with  stout  iodoform  silk.  At  present,  three 
years  after  the  operation,  the  child  appears  to  be  normal  in  every 
respect.  A  comparison  with  the  skiagraph  (Fig.  41),  taken  a 
year  after  operation,  shows  that  the  bony  canal  became  consider- 
ably smaller. 

Union  having  taken  place  by  first  intention,  the  operation  was 
performed  without  administering  an  anaesthetic.  Although  the  loss 
of  blood  was  scant,  the  author's  method  of  prophylactic  suture 
being  used,  there  was  considerable  shock,  lasting  until  an  hour 
and  a  half  after  the  operation.  The  most  predominant  symptom 
was  the  slow  respiration  and  the  anaemia.  The  infant  refused 
nursing  until  two  hours  afterward.  No  stimulants  were  admin- 
istered. . 

As  far  as  the  author's  knowledge  goes,  a  bony  diastasis  of  the 
extent  shown  by  Fig.  39  was  never  represented  before  the  Ront- 
gen  era. 


THE    HEAD  69 

Foreign  Bodies  in  the  Eyeball. — To  locate  foreign  bodies  in  the 
eyeball,  the  exposure  is  best  made  in  the  oblique  direction  (Dahl- 
feld  and  Pohrt  succeeded  even  in  skiagraphing  birdshote  of  the 
size  of  1  to  4  millimetres),  so  that  the  foreign  body  appears 
either  in  front  of  or  behind  the  orbital  margin.     The  localization 


Fig.  41. — Case  of  Hydromeningocele,  illustrated  by  Figs.  39  and  40,   One 
Yeak  after  Operation. 

of  foreign  bodies  in  the  skull  sometimes  encounters  consid- 
erable difficulties.  If  foreign  bodies  are  situated  in  the  bones, 
two  skiagraphs,  at  least,  are  required — one  to  be  taken  anteriorly 
or  posteriorly,  and  the  other  laterally.  By  simply  crossing  their 
diameters  diagonally  the  distance  from  the  outer  surface  can 
be   determined.      The   same   principles   of   localization,   more    or 


70  THE    KONTGEN    KAYS 

less  modified,  apply  to  the  intracranial  localization  of  foreign 
bodies. 

For  localization  of  foreign  bodies  in  the  eyeball  it  is  advisable 
to  place  miniature  letters  at  the  inner  and  outer  end  of  the  eyelid 
and  one  at  the  orbital  margin. 

Extraction  of  Foreign  Bodies  from  the  Skull. — In  extracting 
foreign  bodies  it  has  been  found  quite  helpful  to  measure  the  dis- 
tance of  the  foreign  body  from  the  nearest  bone  prominence  in  both 
skiagraphs;  also  to  compare  the  skiagraph  with  the  features  of  a 
normal  skull.  In  the  case  illustrated  by  Fig.  42  a  bullet  had  en- 
tered the  right  temporal  region,  and,  by  passing  the  orbit  trans- 
versely, caused  traumatic  enophthalmos  (injury  of  the  sympathetic 
roots  of  the  ciliary  ganglion).  The  optic  nerve  was  pierced,  and 
considerable  haemorrhage  of  the  chorioid  and  retina  had  taken  place. 
Neither  the  comminution  of  the  orbit  nor  any  injury  within  the 
extent  of  the  left  antrum  Highmori,  through  which  the  bullet  had 
taken  its  course,  could  be  demonstrated  by  the  rays,  but  the  bullet 
itself  was  located  in  the  left  pterygoid  process.  The  distances  were 
first  measured  during  the  operation  simply  with  a  graded  probe ;  the 
distance  between  the  nasal  bone  and  the  bullet  being  taken  at  the 
frontal  skiagraph  (Fig.  43),  which  determined  the  direction  and 
the  extent  of  the  skin  incision,  and  then  the  same  distance  being 
taken  from  the  lateral  skiagraph  (Fig.  42),  which  determined  the 
depth  of  the  incision.  Although  the  bullet  was  embedded  in  the 
bone  and  surrounded  by  new  bone-tissue,  it  was  not  difficult  to 
detect  and  extract  it  after  the  antrum  of  Highmore  had  been  ex- 
posed by  osteoplastic  resection  of  its  anterior  wall.  Without  the 
aid  of  the  rays  it  would  have  been  impossible  to  trace  the  bullet. 
In  fact,  it  was  remarkable  that  it  had  taken  so  long  and  destructive 
a  course  without  causing  any  other  symptoms  than  a  dull  continu- 
ous pain  all  over  the  skull.  The  bullet  was  so  compressed  that  it 
had  changed  its  longitudinal  form  into  a  flat  disk,  which  explains 
the  peculiar  shape  of  the  bullet  in  the  skiagraph. 

Fractures  of  the  Facial  Bones. — In  fractures  of  the  facial 
bones  skiagraphy  is  of  great  value.  In  one  instance  it  was  pos- 
sible by  skiagraphy  to  illustrate  the  depression  of  the  outer  and 
the  protrusion  of  the  inner  table  in  the  case  of  a  man  of  twenty- 
five  years  who  had  sustained  a  transverse  fracture  of  the  frontal 
bone  when  a  child.  As  the  patient  suffered  from  epileptiform  at- 
tacks after  the  injury,  which  was  originally  taken  only  for  a  super- 


THE    HEAD  71 

ficial   lesion,   osteoplastic   resection  was   performed   fifteen   years 
later.     The  position  found  at  the  operation  verified  the  correct- 


Fig.  43.— Bullet  in  the  Skull  (Lateral  View).    (Compare  Fig.  43.) 


72  THE    KONTGEN    KAYS 

ness  of  the  skiagraph.     The  attacks  have  stopped  since  (the  time 
of  observation  being  four  years  after  the  operation). 

Fractures  of  the  nasal  bones,  the  alveolar  process,  and  the 
zygoma  can  be  represented  by  the  rays.     Skiagraphy  of  the  base 


Fig.  43. — Bullet  in  Skull  (Front  View).    (Compare  Fig.  42.) 

of  the  skull  can  be  relied  on  only  under  very  favourable  circum- 
stances. Fracture  of  the  inferior  maxilla  can  also  be  skiagraphed. 
After  the  fragments  are  wired  it  is  of  value  to  keep  them  under 
control  by  frequent  Bontgen  examinations.  They  often  reveal 
slight  displacement,  which  would  have  escaped  ordinary  inspection. 
At  an  early  stage  simple  pressure  by  the  surgeon's  finger  permits 
of  the  reposition  of  a  projecting  fragment. 

Fig.  44  shows  a  transverse  fracture  of  the  inferior  maxilla 
in  a  lad  of  nineteen  years  wired.  The  fragments  being  in  perfect 
apposition  it  was  self-understood  from  the  beginning  that  the  re- 
sult had  to  be  perfect.  The  same  illustration  shows  the  hyoid 
bone  rather  distinctly. 

Fig.  45  illustrates  a  case  of  fracture  of  the  inferior  maxilla  in 


THE    HEAD 


73 


a  boy  of  eight  years.  The  skiagraph  proved  perfect  apposition 
of  the  fragments,  so  that  simple  immobilization  by  a  plaster-of- 
Paris  dressing  could  be  resorted  to.  It  may  be  noted  tbat  this 
illustration  shows  the  epiglottis  as  well  as  the  outlines  of  larynx 
and  upper  trachea  distinctly. 

Value  in  Rhinology. — The  Rontgen  rays  have  furnished  valu- 
able contributions  to  our  knowledge  of  rhinology.  The  frequent 
presence  of  foreign  bodies  in  the  nose  gives  many  opportunities 
for  their  use.     The  examination  of  the  frontal  sinus  is  of  still 


Fig.  ii.  —Fracture  of  Inferior  Maxilla.  Wired.    (Also  note  hyoid  bone  ) 

greater  importance.  The  absence  of  nasal  bones  and  of  the  hard 
palate  can  be  well  studied  (see  Figs.  29,  142,  and  43).  In  suppu- 
ration of  the  antrum  of  Highmore  the  skiagraph  determines  the 
affected  side,  which  shows  a  much  darker  shade  than  the  normal. 


74 


THE    KONTGEN    RAYS 


Growths  of  the  Inferior  Maxilla. — The  nature  as  well  as  the 
extent  of  a  growth  of  the  inferior  maxilla  can  often  be  ascertained 
by  the  rays.  In  the  case  of  a  man  of  seventy  years,  for  instance,  a 
carcinoma  had  originated  in  the  soft  palate.  Later  on  the  sub- 
maxillary region  became  swollen,  the  joint  finally  participating. 


Pig.  45. — Fracture  of  the  Inferior  Maxilla  Reduced.     (Note  outlines  of  the 
upper  trachea  and  the  epiglottis  ) 


The  question  now  arose  whether  the  swelling  was  the  expression 
of  the  expansion  over  the  maxillary  bones,  which  would  give  the 
case  an  entirely  hopeless  aspect.  But  the  skiagraph  revealed  in- 
tegrity of  the  bones  so  that  an  operation  would  be  advised.  After 
the  oral  cavity  was  thoroughly  disinfected,  the  hard  swelling  dis- 
appeared nearly  entirely.     It  had  consisted  of  a  number  of  en- 


THE    HEAD  75 

larged  glands,  which  were  infected  by  the  decomposed  ulcerating 
surface  of  the  palate.  Tims  the  clinical  course  proved  to  be  in 
harmony  with  the  skiagraphic  representation. 

VALUE  W  DENTISTRY 

The  great  importance  of  skiagraphy  in  dentistry  becomes  more 
and  more  evident.  It  is  to  be  deplored  tbat  the  dentists  do  not 
recognise  this  fact  in  general.  Tbe  relation  of  tbe  dental  roots 
and  their  position,  the  presence  or  absence  of  the  milk-teeth,  as  well 
as  of  the  permanent  teeth  in  children,  or  of  an  old  root,  or  foreign 
bodies  (fillings,  pieces  of  chisel  broken  oif,  for 
instance,  while  excavating  a  carious  tooth), 
the  depth  of  root-filling,  the  proportion  of  the 
antrum  of  Highmore,  and  the  extent  of  an 
alveolar  abscess  can  be  clearly  demonstrated. 

Fig.  -16  shows  a  tooth  whose  filling  had 
caused  alveolar  periostitis  followed  by  the  for- 
mation of  a  fistula.  This  resisted  surgical 
treatment  (removal  of  mandibular  portion,  re- 
peated scraping,  etc. )  for  several  years. 

The   rays    discovered   that   in   filling   the        Filling  in  Tooth. 
molar  excavation  was  overdone,  so.  that  the 
filling  material  was  forced  through  the  root  into  the  inferior  max- 
illa, thus  causing  ostitis.     This  knowledge  suggested  extraction, 
which  cured  the  fistula  promptly. 

The  presence  of  molars,  which  on  account  of  their  deformed 
position  produce  a  painful  teething  process,  can  be  recognised. 
Their  extraction  will  relieve  the  suffering  which  might  have  been 
mistaken  for  neuralgia. 

Disturbances  during  the  period  of  development  are  extremely 
frequent.  The  question  whether  there  is  retention  only  or  com- 
plete absence  is  easily  settled  by  skiagraphy.  The  position  as  well 
as  the  size  and  relations  of  the  teeth  can  be  so  well  ascertained  that 
the  dentist  will  be  able  to  judge  whether  operative  interference  is 
indicated  or  not.  Figs.  47  and  48  show  malposition  of  unerupted 
teeth  in  young  girls.  In  Fig.  47  an  incisor  is  situated  transversely 
in  the  superior  maxilla.  The  exact  diagnosis,  possible  by  the  rays 
only,  enabled  the  dentist  to  place  it  into  a  proper  position.  In 
Fig.  48  the  seat  of  the  malposition  is  in  the  inferior  maxilla. 


76  THE    RONTGEN    EAYS 

Sometimes  it  is  of  great  forensic  importance  to  determine  the 
age  of  an  infantile  corpse  by  skiagraphing  the  teeth. 

As  a  rule,  it  will  suffice  to  place  the  face  portion  nearest  the 
tooth  in  question  on  an  ordinary  Eontgen  plate.     If  fine  details 


Fig.  47. — Incisor,    situated   transversely   in   the    Superior    Maxilla   of   a 
Girl  of  Fifteen  Years. 

are  demanded,  flexible  films  may  be  introduced  into  the  oral  cav- 
ity, where  they  will  adapt  themselves  to  the  contours  of  the  max- 
illa.    Special  metal  film-holders  must  be  used  for  that  purpose. 


THE    HEAD  77 

Such  holders  can  be  placed  on  the  teeth,  the  patient  being  able  then 
to  close  his  mouth. 

Cartridges  of  H-inch  film,  generally  used  for  the  Brownie 
camera,  may  be  used  for  short  exposures. 

Especially  the  anterior  upper  and  Lower  incisors,  tbe  upper  and 
lower  canines,  the  premolars  and  the  first  molars  of  the  superior 
as  well  as  of  the  inferior  maxilla  can  be  well  represented  by  the 
intraoral  method.  The  upper  and  lower  posterior  molars  have  to 
be  skiagraphed  from  the  outside. 

Whenever  a  longer  exposure  is  required  the  film  is  best  inclosed 


Fig.  48. — Transvekse  Tooth  in  the  Mandible. 

in  unvulcanized  rubber,  after  being  envelopd  in  tissue  paper. 
Thus  adherence  of  the  rubber  to  the  film  is  prevented. 

The  film  must  be  placed  in  such  a  manner  that  it  faces  the 
Eontgen  tube,  the  rays  reaching  it  in  a  perpendicular  direction. 
In  skiagraphing  the  front  teeth  the  face  is  directed  upward  and 
the  chin  drawn  toward  the  sternum  in  order  to  obtain  a  correct 
perspective.  The  distance  of  the  film  from  the  tubal  wall  should 
not  be  less  than  6  inches. 

As  to  differentiation,  it  must  be  borne  in  mind  that  diseases  of 
the  maxillae  are  often  mistaken  for  dental  affections.  Caries  and 
necrosis,  producing  sequestra,  are  sometimes  treated  for  simple 
toothache,  the  clinical  symptoms  sometimes  being  veiled.  In  such 
cases  the  rays  not  only  give  the  correct  information,  but  also  fur- 


78  THE    RONTGEN    EAYS 

nish  the  guide  for  the  proper  surgical  therapy.  Fistulae  and  cysts 
have  to  be  considered  from  the  same  points  of  view. 

In  a  case  of  severe  neuralgia  the  question  arose  whether  an  old 
root  was  the  cause  of  the  evil.  The  skiagraph  showed  that  the 
small  screw  of  the  adjacent  artificial  tooth  had  been  attached  in 
a  wrong  direction.    After  it  was  unscrewed  the  pain  ceased. 

The  presence  of  a  gumma  also  puzzles  the  dentist,  the  question 
whether  the  swelling  be  due  to  syphilis  or  to  an  old  dental  root 
not  being  solved  except  the  rays  come  to  his  rescue.  (See  Chapter 
XIII  on  Diseases  of  the  Bones  and  Joints.)  The  fact  should  not 
be  lost  sight  of  that  old  roots  undergo  atrophy  in  the  course  of  time, 
so  that  they  appear  small  and  thin.  This  explains  why  they  may 
be  overlooked  in  a  mediocre  skiagraph. 


CHAPTER    VII 
NECK 

The  neck  may  be  fluoroscoped  us  well  as  skiagraphod  while 
the  patient  is  seated  on  a  chair,  but  for  skiagraphy  it  is  better  to 
have  the  patient  reclining  on  a  table  or  the  floor,  a  small  pillow 
supporting  the  head.  The  best  exposures  of  the  upper  cervical 
vertebrae  are  made  by  turning  the  patient  sidewise.  In  this  posi- 
tion the  cervical  vertebra  are  better  shown,  the  angle  of  the  max- 
illa not  overshadowing  their  upper  portion.  The  dark  shade  of 
the  hyoid  bone,  as  well  as  the  lighter  shadow  of  the  larynx,  the 
epiglottis,  and  the  trachea  are  well  represented  (see  Figs.  44  and 
45).  The  oesophagus,  while  not  conspicuous,  can  be  made  out 
behind  the  trachea  as  a  hollow  space.  The  bodies,  the  spinous, 
and  the  transverse  processes,  as  well  as  the  intervertebral  foramina, 
appear  very  conspicuous.  For  the  lower  cervical  vertebras  the  re- 
cumbent position  may  be  chosen,  the  patient's  occiput  reclining  and 
his  chin  being  elevated.  Fixation  is  done  best  by  surrounding 
the  head  and  neck  with  sand-bags.  The  atlas  shows  its  character- 
istic outlines  very  distinctly,  while  the  epistropheus  is  recognised 
by  its  bifurcated  spinous  process. 

Aneurysm  of  the  carotid  and  the  subclavian  arteries  is  demon- 
strable. Tumours  of  the  larynx,  especially  chondroma  and  ossifi- 
cation, goitre  and  concretions  in  the  submaxillary  gland  are  easily 
recognised. 

Exploratory  incision  for  suspected  foreign  bodies  in  the  phar- 
ynx, tonsils,  larynx,  trachea,  and  oesophagus  have  become  unneces- 
sary. The  rays  as  explorers  have  indeed  realized  the  old  ideal 
desideratum:  Cito,  tuto  et  jucunde.  Whoever  has  felt  the  uncer- 
tainty in  diagnosticating  foreign  bodies  in  these  regions,  and  espe- 
cially who  has  been  tempted  to  resort  to  adventurous  procedures, 
must  keenly  feel  the  blessings  which  the  rays  have  brought.  If 
the  Eontgen  rays  had  done  nothing  else  but  locate  foreign 
bodies  in  the  throat,  they  would  represent  one  of  the  greatest 
blessings  to  suffering  humanity.  Metallic  bodies,  such  as  needles, 
coins,   or  bone-fragments  and  buttons  are  easily  recognised  by 

79 


80  THE    RONTGEF    RAYS 

fluoroscopy;,  and  may  be  extracted  through  a  tracheotomy-wound 
under  the  guidance  of  the  bronchoscope.  Artificial  teeth  usually 
show  also  well,  while  shells  of  a  nut  or  a  splinter  of  wood  are 
demonstrable  under  favourable  circumstances  only. 

Foreign  Bodies  in  the  (Esophagus. — As  illustration  of  the  re- 
moval of  a  coin  the  following  case  may  be  mentioned :  A  baby  of 
one  year  old  had  swallowed  a  penny  nine  days  before  the  author 
saw  it.  When  examined  first  it  was  decided  that  the  foreign  body 
had  passed  the  oesophagus.  The  mother  watched  the  faeces  of  the 
patient  carefully,  but  did  not  find  the  penny.  In  the  meanwhile 
the  baby  became  feverish  and  vomited  frequently.  When  the  child 
was  first  seen  it  gave  the  impression  that  a  grave  disease  was  pres- 
ent. Instead  of  introducing  an  oesophageal  probe,  as  was  done  in 
former  years  in  such  cases,  the  fluoroscope  was  used,  which  located 
the  penny  at  once  on  a  level  with  the  second  rib.  A  coin  catcher 
was  then  introduced.  After  having  passed  the  isthmus  a  resistance 
was  felt;  the  instrument  was  then  pushed  forward,  turned,  and 
withdrawn  until  considerable  resistance  was  encountered,  when  the 
steel  attachment  of  the  coin  catcher  broke,  so  that  coin  and  catcher 
were  both  in  the  oesophagus.  After  many  unsuccessful  efforts,  the 
broken  fragment  of  the  coin  catcher  was  extracted  (with  an 
oesophageal  forceps).  The  coin  was  now  propelled  into  the  stom- 
ach with  a  whalebone  pusher.  No  sooner  was  this  accomplished 
than  the  child  vomited  and  the  penny  was  ejected. 

Fig.  49  shows  the  skiagraph  of  a  child  of  two  years  who  swal- 
lowed a  5-cent  piece  six  days  before  Rontgen  examination  was 
resorted  to,  the  child  not  having  shown  any  grave  symptoms  dur- 
ing the  first  few  days.  On  the  fifth  day  respiratory  disturbances 
were  noted.  When  the  writer  saw  the  child  six  days  after  the  acci- 
dent he  could  locate  the  coin  at  the  level  of  the  first  rib. 

Extensive  bronchopneumonia  had  supervened  in  the  meanwhile. 
The  frequent  respiratory  movements  made  it  very  difficult  to  ob- 
tain a  good  skiagraph.  In  spite  of  the  great  restlessness  of  the 
patient  an  exposure  of  fifteen  seconds  sufficed  to  produce  a  dis- 
tinct representation  of  the  coin.  The  plate  also  shows  the  rami- 
fications of  the  bronchi. 

The  extraction  of  the  coin  was  done  too  late  and  the  child 
succumbed  to  pneumonia.  This  is  the  regular  course  of  such  cases 
if  their  nature  is  recognised  too  late.  Nowadays  there  is  no  ex- 
cuse for  such  procrastination. 


82  THE    RONTGEN    RAYS 

Another  remarkable  case  is  that  of  a  girl  of  fifteen  years,  who, 
on  the  evening  previous  to  the  examination,  had  held  a  needle 
between  her  teeth,  which,  when  frightened  by  a  sudden  noise,  she 
swallowed.  Medical  care  was  summoned  at  once.  The  distinct 
pain,  located  at  the  region  of  the  first  and  second  dorsal  verte- 
brae, was  attributed  to  the  injury,  which  had  presumably  been 
caused  by  the  needle  passing  the  oesophagus.  The  pain  becoming 
more  intense  during  the  night,  the  patient  was  brought  to  the 
hospital,  where,  after  being  under  anaesthesia,  she  was  advised  that 
the  needle  was  in  the  stomach  and  would  soon  pass  per  vias  naturales. 

Later,  when  the  neck  was  examined  with  the  fluoroscope,  the 
needle  was  found  at  a  level  with  the  first  rib.  By  introducing  the 
finger  into  the  oesophagus,  the  needle  could  be  distinctly  felt  at 
this  region,  and  was  successfully  dislodged,  so  that  it  was  possible 
to  extract  it  with  an  oesophageal  forceps.  Without  the  fluoroscope 
it  would  not  have  been  possible  to  progress  with  such  absolute 
certainty. 

If  the  fluoroscopic  examination  had  not  been  successful,  the 
thorax  and  abdomen  should  have  been  skiagraphed  and  the  for- 
eign body  would  probably  have  been  located  somewhere  in  the 
oesophagus  or  the  stomach. 

Gocht  reported  the  case  of  a  patient  who  had  been  submitted 
to  repeated  operative  procedures  on  account  of  severe  pain  in  one 
of  his  tonsils  without  obtaining  any  relief.  The  Rontgen  rays  re- 
vealed a  needle  fragment  deeply  embedded  in  the  tonsillar  tissue, 
where,  of  course,  it  had  been  inaccessible  to  palpation. 

Fractures  of  Hyoid  Bone,  Larynx,  and  Vertebrae. — Two  years 
ago  (New  York  German  Medical  Society)  the  writer  reported  the 
case  of  a  woman  of  twenty-one  years,  who,  in  falling  downstairs 
during  an  epileptic  fit,  sustained  a  fracture  of  the  right  transverse 
processes  of  the  first,  second,  and  third  cervical  vertebrae.  That 
there  was  a  fracture  within  the  cervical  vertebrae  was  at  once 
recognised  by  the  family  physician,  but  its  localization,  and  espe- 
cially the  fact  that  only  the  transverse  process  was  concerned,  could 
be  verified  only  by  means  of  the  Rontgen  rays. 

Reduction  was  accomplished  under  the  guidance  of  the  Ront- 
gen rays.  One  of  the  vertebral  fragments  was  felt  as  a  protruding 
mass  from  the  posterior  pharyngeal  wall  and  was  pushed  backward. 
The  after-treatment  consisted  in  the  application  of  Glisson's 
cradle.    Recovery  was  perfect  after  nine  weeks. 


NKCK 


83 


Goitre. — The  various  types  of  goil  re,  viz.,  the  colloid,  cystic,  and 
parenchymatous,  show  different  anatomic  conditions.     The  colloid 

type  shows  a  few  coarse  non-fluctuating  nodules  while  the  cystic  is 
globular  in  shape  and  distinctly  fluctuating.    The  parenchymatous 
type  is  distinguished   by  its  regu- 
lar coarse-grained   structure. 

Sclerotic  and  hyaline  degener- 
ation of  the  connective  tissue 
leads  to  calcareous  deposits  in  the 
course  of  time.  Thus  areas  of 
fibrous  as  well  as  myxomatous 
goitre  may  become  petrified.  Sin- 
gle cysts  may  also  become  calci- 
fied. The  clinical  diagnosis  of 
conditions  of  this  kind  is  based 
upon  the  resistance  of  the  tissues, 
while  the  vascular  types  are  rec- 
ognised by  the  pulsation,  the 
bruit,  and  the  compressibility. 

There  is  a  variety  of  goitre, 
however,  the  type  of  which  can 
be  recognised  neither  by  inspec- 
tion nor  by  palpation  or  the  laryngoscope.  This  is  deplorable, 
because  the  mode  of  therapy  is  influenced  by  the  detailed  diagnosis. 
Sometimes  a  puncture  may  show  the  degree  of  density  of  the  tis- 
sues. If  the  needle  comes  into  contact  with  calcareous  deposit 
grating  is  perceived.     Then,  of  course,  the  diagnosis  is  easy. 

But  differentiation  by  the  Eontgen  rays  is  much  simpler.  In 
the  frequent  cystic  or  fibrous  varieties  the  calcareous  deposits  can 
be  well  demonstrated  by  skiagraphy.  (See  Allgemeines  fiber  den 
Kropf  und  seine  Behandlung.  New  Yorker  Medicinische  Mo- 
natsschrift,  October,  1900.)  Whenever  the  calcereous  deposits 
were  found  the  injection  of  iodoform-ether,  which  gives  splendid 
results  in  the  follicular  and  colloid  types,  was  not  tried.  Extirpa- 
tion was  resorted  to  then,  provided  there  was  enough  disturbance 
to  justify  such  radical  steps. 

Fig.  50  (compare  Fortsehritte  auf  dem  Gebiete  der  Rontgen- 
strahlen,  Hamburg,  Bd.  iv)  represents  the  case  of  a  woman  of 
thirty-two  years  who  suffered  from  a  goitre  of  the  size  of  a  man's 
fist.    Iodoform-ether  injections  were  tried  without  success,  the  rea- 


Fig.    ;j0. 


-GoiTKE     CONTAINING    CAL- 
CAREOUS Matter. 


84  THE    KONTGEN    RAYS 

son  of  which  was  explained  by  the  presence  of  two  well-marked  cal- 
careous foci  in  the  skiagraph  (Fig.  51).  This  showed  the  char- 
acter of  the  growth  to  be  a  cystic  goitre  associated  with  calcareous 
deposits.      In   such   cases   the   injection   treatment    always    fails, 


Fig.   51.— Skiagraph   of   Calcareous   Deposits    in     Goitre,   illustrated  by 

Fig.  50. 

therefore  extirpation  has  to  be  resorted  to,  provided  the  disturb- 
ance justifies  so  severe  a  procedure. 

In  retrosternal  goitres  it  can  be  ascertained  by  skiagraphy  how 
far  they  extend  to  the  mediastinum. 

Tuberculous  glands  are  faintly  shown  if  they  are  thick  and 
contain  cheesy  deposits.  Calcareous  degeneration,  of  course,  can 
be  distinctly  represented. 

Never  before  was  the  inadequacy  of  our  radical  endeavours 
more  clearly  illustrated  to  me  than  by  skiagraph  Fig.  52,  which 
represents  the  case  of  a  woman  of  twenty-eight  years,  whose  tuber- 
culous glands  were  repeatedly  removed  from  her  neck  during  the 
last  nine  years.  The  last  recurrence  showed  a  number  of  fairly 
large  and  coherent  glands,  the  capsules  of  which  adhered  among 
themselves.    Their  contents  consisted  in  cheesy  pus  mixed  with  cal- 


NECK 


85 


careous  masses.  In  view  of  the  history,  it  was  natural  that  the 
most  thorough  removal  of  suspicious  tissue  was  contemplated.  In 
order  to  gain  access  to  a  large  area  the  sterno-cleido-mastoid  mus- 
cle was  divided  transversely.  Now  the  superficial  glandular  chains 
could  be  easily  removed,  but  in  the  deeper  strata  it  appeared  diffi- 
cult to  reach  the  many  small  glandular  globules.  Still  the  author, 
after  having  extirpated  every  suspicious  globular  element  between 
the  interstices,  felt  contented  that  he  had  at  least  removed  all  cal- 
careous glands.  He  could  well  appreciate  that  a  few  of  the  small 
soft  recent  glands  could  escape  palpation,  but  he  did  not  assume 
that  the  hard  calcareous  masses  could  not  be  felt.  Still  the  monu- 
mental impoliteness  of  the  rays  showed  shortly  afterward  that  no 


Fig.  52  —Tuberculous  Glakds  of  .Neck. 


less  than  thirty  small  calcareous  glands  were  left.  The  importance 
of  a  demonstration  of  this  kind  is  evident,  and  suggests  repeated 
operative  steps.  It  shows  at  the  same  time  how  important  con- 
stitutional post-operative  treatment  is  in  such  cases. 


CHAPTER    VIII 

CHEST 

As  emphasized  in  the  General  Part,  the  screen  displays  its  mam 
virtues  in  the  diagnosis  of  the  diseases  of  the  chest,  since  it  per- 
mits of  the  observation  of  organs  while  they  are  in  continuous 
motion.  The  number,  rhythm,  and  shape  of  the  various  motions 
can  be  distinctly  studied. 

The  chest  may  be  fluoroscoped  while  the  patient  is  standing  or 
seated  on  a  chair  provided  with  a  low  back.  As  to  the  peculiarities 
of  other  positions,  reference  is  made  to  the  general  part  on  fluoros- 
copy. As  a  rule,  soft  tubes  should  be  used  for  thoracic  examina- 
tion, the  harder  variety  being  preferred  for  the  representation  of 
dense  foreign  bodies  only.  The  dorsal  vertebra?,  the  ribs,  the 
clavicle,  their  injuries,  diseases,  and  malformations  (supernumer- 
ary ribs)  can  be  well  seen.  The  heart,  the  lungs,  the  pleura,  and 
the  diaphragm  can  be  studied  thoroughly.  Foreign  bodies  in  the 
thoracic  cavity  are  easily  recognised,  and  most  diseases  of  the 
thoracic  cavity,  so,  for  instance,  enlargement  or  displacement  of 
the  heart  and  effusion  in  the  pericardium,  as  well  as  aneurysm 
and  the  various  kinds  of  mediastinal  tumours  can  be  studied. 

Pneumonic  solidification,  phthisical  foci,  cavities,  abscesses, 
tumours,  bronchiectasis,  emphysema,  and  retractions  of  the  lungs 
can  be  recognised  by  fluoroscopy  as  well  as  by  skiagraphy.  Effu- 
sions in  the  pleural  cavity,  also  fibrous  swards  of  the  pleura  and 
irregularities  of  the  excursions  of  the  diaphragm  are  noted. 

For  skiagraphing  the  patient  an  even  table  of  strong  construc- 
tion or  the  carpeted  floor  is  selected.  Posterior  irradiation  is  done 
in  the  dorsal  position,  the  spinal  column,  as  well  as  the  posterior 
portions  of  the  ribs  with  their  heads,  necks,  and  tubercles  becom- 
ing apparent,  especially  at  their  right  side.  The  direction  of  the 
posterior  ribs  is  downward,  while  that  of  the  anterior  is  upward. 
The  image  of  the  anterior  aspect  of  the  ribs  is  naturally  diffused 
on  account  of  the  much  greater  distance  from  the  plate.  Soft 
86 


CHKST 


87 


tubes  show  the  ribs  best,  the  time  of  exposure  not  to  exceed  three 
minutes. 

In  skiagraphing  anteriorly  by  posterior  irradiation,  the  patient 

lying  on  his  abdomen,  the  clavicle,  the  sternum,  and  the  adjoining 
ribs  can  be  well  defined.    The  distinctness  of  the  skiagraph  suffers, 


Mm  sternohyoid  rl  stemothyrcoid 

Trac/iea 


Clavjcti//i 
M  subclaims 


Col  u-ansv 
Col  drscendens 


Fig.  53. — Topographic  Relations  of  Intrathoracic  Viscera. 
(After  Waldeyer.) 


88  THE    RONTGEN    RAYS 

however,  on  account  of  the  patient's  oppressed  respiration.  On  ac- 
count of  the  distance  the  spinal  column  and  the  posterior  ribs 
appear  diffused.  The  heart  being  situated  so  near  the  anterior 
chest  wall,  shows  its  outline  well  marked.  The  shadow  of  the  large 
blood-vessels  is  less  distinct.  The  shadows  of  the  normal  lungs, 
especially  the  middle  portions,  are  extremely  light. 

The  upper  dorsal  vertebrae,  as  far  as  they  are  not  obstructed  by 
the  shadows  of  the  heart  and  the  large  vessels,  show  fairly  well. 
The  same  applies  to  the  three  left  dorsal  vertebrae.  The  other 
portions  of  the  spinal  column  appear  indistinct  within  their  extent 
of  the  thorax.  Abscesses  can  sometimes  be  recognised  in  this  re- 
gion by  using  the  diaphragm.  The  outlines  appear  more  marked 
in  oblique  projection,  but  there  the  skiagraph  becomes  considerably 
distorted. 

The  sternum  is  best  represented  by  a  short  exposure.  For  this 
purpose  a  hard  tube  must  be  chosen,  the  patient  being  requested 
to  hold  his  breath  for  half  a  minute.  The  sterno-clavicular  junc- 
tion, tumours,  capillary  gummata,  are  frequently  noted.  For  com- 
parison the  normal  anatomic  relations  of  the  thorax  should  always 
be  kept  in  mind  (Figs.  53  and  123.) 

In  regard  to  the  study  of  the  diseases  of  the  lungs  it  may  be 
maintained  that  whoever  does  not  master  the  principles  of  auscul- 
tation and  percussion  is  not  fit  to  comprehend  the  fluoroscopic  or 
skiagraphic  signs.  There  are  conditions  in  these  organs  that  can 
be  better  elicited  by  the  so-called  physical  methods,  and  others  that 
can  be  ascertained  only  by  means  of  the  Rontgen  rays.  While  the 
rays  show  small  tumours  or  infiltrated  foci  which,  on  account  of 
their  central  location,  cannot  be  diagnosed  by  the  old  physical 
methods,  they  have  the  disadvantage  of  always  showing  the  tho- 
racic image  in  toto — that  is,  they  represent  all  the  shadows  of  the 
tissue  situated  before  as  well  as  behind  the  diseased  area  at  the  same 
time. 

At  the  early  stage  of  tuberculosis  of  the  lungs  valuable  informa- 
tion can  be  derived  from  irradiation.  Williams  found  the  dia- 
phragm abnormally  high  at  the  affected  side  in  incipient  tubercu- 
losis on  fluoroscopic  examination. 

Solidification  and  atelectasis,  as  well  as  exudation  and  calcifica- 
tion, can  be  well  demonstrated.  The  infiltrated  walls  of  cavities 
are  recognised  as  more  or  less  distinct  shadows  surrounding  a  light 
area.    The  true  nature  of  the  various  shadows  is  often  better  un- 


CHEST  89 

derstood,  if,  after  previous  skiagraphies  representation,  the  thorax 
is  also  fluoroscoped  in  different  positions.  In  that  case  we  see  the 
area  which  causes  bronchial  breathing,  so  to  say,  instead  of  aus- 
cultating it.  Fig.  54  represents  extensive  tuberculous  foci  in  the 
right  lung  of  a  woman  of  thirty-five  years. 

The  large  number  of  the  foci  and  their  partial  confluence 
point  to  an  advanced  stage.  Clinical  observation  corroborates 
this  assumption.  The  sharply  outlined  obscure  foci  are  of  an  older 
date,  while  the  light  .shadows  surrounded  by  foggy  contours  indi- 
cate recent  destruction. 

Localization  of  abscess,  echinococcus,  and  gangrene  of  the 
lungs  by  the  screen  must  be  done  in  various  positions.  The  tis- 
sue-defects appear  as  light  shadows,  with  which  the  surrounding 
cavity  walls  contrast  as  dark  shadows  of  an  irregular  circular  or 
elliptic  shape.  If  the  shadow  shows  in  the  abdominal  position  as 
well  as  it  does  in  the  dorsal,  it  must  be  centrally  located. 

In  gangrene  the  gradual  clearing  up  of  the  formerly  solidified 
area  is  observed.  Similar  views  apply  to  echinococcus.  (See 
Echinococcus  of  the  Lungs.  Journal  of  the  American  Medical 
Association,  November  19,  1898.) 

Fig.  55  illustrates  the  case  of  a  man  of  thirty-five  years,  who 
was  stabbed  in  the  back.  Little  reaction  following  at  the  time,  an 
injury  of  the  lungs  was  not  thought  of  until,  three  days  later, 
chills,  haemoptysis,  and  pleuritic  symptoms  announced  the  devel- 
opment of  pleuropneumonia.  Later  a  purulent  effusion  was  dis- 
charged by  simple  thoracotomy. 

The  suppuration  continuing,  a  resection  of  a  rib  was  performed 
a  few  months  later.  The  patient  improved  then,  but  recovery  did 
not  take  place.  Three  years  after  the  injury,  when  the  author  ex- 
amined the  patient  for  the  first  time,  moderate  dyspnoea,  dimin- 
ished bronchial  breathing  and  rhonchi  were  observed.  Elastic 
fibres  were  also  found.  The  injection  of  liquids  into  the  fistulous 
tract  produced  violent  attacks  of  coughing.  A  few  minutes  after 
the  introduction  of  a  strip  of  iodoform  gauze  the  patient  noted  a 
decided  taste  of  iodoform  in  his  mouth.  After  having  gained 
access  to  the  pleura  by  the  exploratory  method  (see  Exploratives 
Princip  und  Technik  beim  secundaerem  Brustschnitt.  Archiv  fur 
klinische  Chirurgie,  Esmarch-Festschrift)  the  margins  of  the 
pleural  canal  showed  themselves  considerably  hypertrophied  in 
some  portions.     The  diameter  of  some  of  the  swards  amounted  to 


90 


THE    ROXTGEN    RAYS 


an  inch.    After  these  fibrous  areas  were  removed,  access  was  gained 
to   a   pulmonary   cavity   of   moderate   extent.      The   granulations 


which  lined  it  were  removed  and  a  loose  packing  with  iodoform 
gauze  used. 


(IIKST 


91 


A  probe  introduced  into  the  cavity  showed  a  depth  of  16  centi- 
metres. The  question  of  localization  could  be  well  studied  in  tin's 
case  by  introducing  a  penny,  enveloped  in  gauze,  into  the  cavity 


Fig.  55. — Abscess  of  Lungs. 


and  then  attaching  the  lead-letters  outside  of  the  thorax  (see 
General  Part)  by  adhesive  plaster.  Thus  the  point  of  convergence 
of  two  lines  can  be  constructed. 


92  THE    RONTGEX    EAYS 

The  skiagraph  shows  penny  and  probe  and  the  various  shadow 
tints — viz.,  the  very  light  centre  indicating  the  abscess  cavity  and 
the  slightly  darker  outlines  of  the  upper  portion  of  its  wall.  The 
lower  margin  is  overshadowed  by  the  fragment  of  the  eighth  rib. 
At  a  slight  distance  from  the  abscess  wall  the  dark  margins  of  the 
remainder  of  the  thickened  pleura  can  be  recognised. 

The  surgical  treatment  of  tuberculous  cavities  does  not  show 
many  encouraging  results.  If  the  rays,  however,  show  a  large 
solitary  cavity,  exposure  and  drainage  should  be  attempted,  pro- 
vided other  pulmonal  areas  are  but  little  involved. 


PLEURA 

Pleuritic  effusions  show  a  marked  opacity  through  the  fluoro- 
scope.  The  larger  the  amount  of  effusion  the  greater  the  degree 
of  opacity.  In  pyothorax  the  opacity  is  somewhat  less  complete 
than  in  serothorax. 

Especially  on  the  right  side  the  outlines  of  the  liver  show  a 
marked  contrast  to  the  lower  boundary-line  of  the  effusion.  The 
inner  boundary-line  of  the  effusion  generally  appears  convex,  but 
if  the  patient  inspires  deeply,  or  if  he  coughs  violently,  it  loses 
its  convexity  and  becomes  horizontal.  By  changing  the  position 
of  the  patient,  of  course  displacements  of  the  effusions  are  ob- 
served accordingly.  Uniform  transparency  above  the  effusion 
points  to  the  result  of  a  simple  inflammatory  process,  while  con- 
stant opacities  of  an  irregular  appearance  justify  a  suspicion  of  a 
beginning  tuberculosis. 

As  a  rule,  it  is  found  that  the  area  of  dulness  corresponds  to  the 
area  of  shadow. 

Pyothorax. — The  diseased  tissues  in  pyothorax  show  a  greater 
density  than  those  of  the  lungs.  The  diaphragm  appears  to  be 
depressed. 

The  extent  of  a  pyothoracic  cavity  may  be  estimated  by  filling 
it  with  iodoform  glycerin  or  with  a  solution  of  iodide  of  potassium. 
Water  will  also  produce  a  shadow.  The  subnitrate  of  bismuth, 
which  is  not  permeable  by  the  rays,  furnishes  a  still  more  marked 
contrast ;  but  as  it  interferes  with  the  treatment,  its  use  cannot  be 
recommended  for  this  especial  purpose.  The  screen  also  shows  the 
degree  of  expansibility  of  the  compressed  lung.     The  rays  prove 


CHEST 


93 


that,  after  subperiosteal,  sometimes  even  after  total  resection  of  a 
rib,  the  exsected  portion  is  more  or  Less  reformed. 

Fig.  5G  illustrates  the  case  of  a  boy  of  nine  years  in  whom  re- 
covery from  pyothorax  of  three  years'  standing  was  obtained  after 
resection  of  the  fifth,  sixth,  seventh,  and  eighth  ribs  and  a  portion 


Pig.   5G 


-Fifth,   Sixth,   Seventh,   and  Eighth  Ribs,   Three   Weeks  after 
Resection  for  Old  Pyothorax. 


of  the  scapula.     The  bone  proliferations  could  be  demonstrated  as 
early  as  three  weeks  after  resection. 

Hydropneumothorax  shows  the  very  dark  outlines  of  the  exuda- 
tion in  contrast  to  the  light  shadow  of  that  intrathoracic  area 
which  contains  air.  The  dark  boundary-line  of  the  exudation  can 
be  recognised  by  the  screen  as  an  ascending  and  descending  line 
during  the  respiratory  movements. 


94  THE  RONTGEN  RAYS 

HEART 

The  patient  may  be  examined  in  the  sitting  as  well  as  in  the 
recumbent  posture.  The  tube  should  be  as  near  to  the  thorax  as 
possible,  but  it  must  not  be  overlooked  that  the  size  of  the  shadow 
of  the  heart  is  exaggerated.  For  proper  interpretation  the  dis- 
tance of  the  tube  must  therefore  be  noted,  especially  if  tracing  is 
done  for  later  comparison. 

The  importance  of  recognising  an  enlargement  of  the  heart  is 
evident.  Our  physical  methods  are  so  highly  developed  that  the 
diagnosis  of  an  enlargement  will  seldom  be  difficult.  In  some  in- 
stances, however,  comparison  can  be  made  with  a  higher  degree  of 
mathematical  exactness  by  the  Rontgen  method  than  percussion 
would  permit.  So,  for  instance,  Schott  (Nauheim)  could  demon- 
strate that  the  hearts  of  bicyclists  were  temporarily  enlarged  after 
a  great  exertion. 

Our  knowledge  of  the  effects  of  valvular  lesions,  of  fatty  de- 
generation, aneurysm,  sclerosis,  pericardial  adhesions,  etc.,  became 
very  much  increased  by  fluoroscopic  examination. 

Fig.  57,  for  instance,  shows  the  Irypertrophied  heart  of  a  girl  of 
eleven  years  after  an  attack  of  rheumatic  endocarditis. 

The  movements  of  the  heart  can  be  thoroughly  studied,  its 
regular  contractions  especially  being  easily  observed.  For  exact 
measuring,  the  various  stages  of  respiratory  movements  must  be 
carefully  noted,  so  that  no  errors  occur  when  comparison  is  made 
with  later  results.  The  pulsations  are  most  marked  during  the 
stage  of  expiration.  The  observations  of  Williams  and  Benedikt 
proved  that  some  physiological  errors  in  regard  to  the  mode  of 
contraction  of  the  heart  existed.  That  the  heart  does  not  empty 
itself  completely  at  each  systole  becomes  evident  by  the  presence  of 
a  large  blood-shadow.  Thus  we  learn  that  the  contractions  of  the 
heart  are  not  of  the  extent  assumed  heretofore.  In  proportion  to 
the  amount  of  blood  filling  the  ventricles  the  shadow  of  the  apex 
appears  lighter  or  darker. 

During  deep  inspirations  it  can  be  observed  that  the  diaphragm 
becomes  distant  from  the  heart,  which  proves  that  the  heart  is  sus- 
pended by  its  blood-vessels  and  is  not  supported  by  the  diaphragm. 
Full  inspiration  shows  the  lungs  more  translucent,  so  that  their 
shadow  appears  in  greater  contrast  to  the  dark  outlines  of  the 
heart. 


CHEST  95 

The  importance  of  ascertaining  the  accurate  size  of  the  heart 
by  skiagraphy  should  not  be  underestimated.  For  this  end  at 
least  two  skiagraphs,  under  different  projection  planes,  should  be 
made.    The  principles  of  localization  should  be  well  observed  (see 


Pig.  57  — Hypertrophy  of  Left  Ventricle  after  Rheumatic  Endocarditis. 

General  Part).  For  dextrocardia,  see  description  of  case  of  left- 
sided  cholecystostomy  (p.  112). 

Pericarditis  is  sometimes  caused  by  a  fracture  or  rib-fragment 
which  has  pierced  the  pericardium. 

A  trauma  of  this  kind  may  be  elicited  by  the  Rontgen  rays.  If 
the  clinical  symptoms  are  slight,  the  rays  showing  no  displaced 
splinters,  expectant  treatment  is  entirely  justifiable.  Fven  if  a 
bullet,  after  having  fractured  a  rib,  has  entered  the  pericardium, 
there  may  be  no  need  of  surgical  interference,  providing  no  severe 
symptoms  are  present. 

In  a  man  who  was  shot,  eight  years  before  his  death,  into  the 
supraclavicular  fossa  from  above,  the  bullet  could  be  located  at 
the  apex  of  the  heart.     The  patient  had  never  suffered  from  any 


96  THE    RONTGEN    RAYS 

symptoms  pointing  to  the  presence  of  the  bullet.  At  the  autopsy, 
performed  at  the  St.  Mark's  Hospital,  the  bullet  was  found  em- 
bedded in  fibrous  tissue  in  the  pericardium. 

The  evidence  of  a  large  bone-splinter  pointing  towards  the 
pericardium  is  an  urgent  indication  for  exposing  the  pericardial 
sac  after  the  resection  of  the  left  fourth,  fifth,  and  sixth  ribs. 
These  need  not  be  resected  in  their  totality,  but  may  be  folded  up 
at  their  sternal  junctions  like  a  bone  flap  of  the  skull.  The  diag- 
nosis of  pericardial  adhesions  may  also  be  verified  by  the  fluoro- 
copic  screen,  which  would  show  limited  expansion. 

Sclerosis  of  the  Arteries. — The  diagnosis  of  arteriosclerosis, 
while  very  easy  on  the  surface  of  the  bod}r,  was  very  difficult  in  the 
deeper  tissues.  According  to  the  text-books  on  internal  medicine, 
the  thickening  of  the  tunica  intima  cannot  be  recognised  if  it  be 
confined  to  a  small  area  or  to  single  small  foci.  It  hardly  need 
be  emphasized  how  important  it  is  to  know  whether,  in  a  given 
case  of  sclerosis  of  the  radial  artery,  foci  in  other  vessels  exist. 
Neither  can  the  number  of  these  obstructive  foci  be  a  matter  of  in- 
difference, nor  whether  a  large  artery,  such  as  the  aorta,  or  only  a 
small  one,  such  as  the  temporal,  is  concerned.  The  presence  of  a 
large  number  of  foci  means  a  loss  of  propelling  energy  in  the  circu- 
lation, which  can  be  compensated  only  by  the  increased  working 
power  of  the  left  ventricle.  The  arterial  pressure  thus  becoming 
higher,  hypertrophy  of  the  overworked  ventricle  will  be  the  most 
natural  consequence.  If  such  foci  are  recognised  at  an  early  stage, 
proper  prophylaxis  can  accomplish  a  great  deal  in  preventing 
secondary  disturbances.  The  prognostic  significance  of  an  exact 
knowledge  of  the  condition  of  the  arteries  is  also  evident.  The 
Eontgen  rays  give  us  a  more  reliable  method  of  ascertaining 
this  condition  of  the  vessels,  and  this  in  nearly  every  part  of 
the  body.  So-called  intermittent  limping  is  thus  sometimes  ex- 
plained by  the  early  recognition  of  sclerosis  of  the  arteries  of 
the  foot. 

Sclerosis  of  the  arteries  points  to  lues  sometimes.  In  such 
cases  palpation  of  the  radial  artery  might  reveal  nothing  abnormal, 
while  skiagraphy  of  the  tibialis  antica  and  postica  shows  cal- 
careous degeneration. 

In  a  case  of  sclerosis  of  both  radial  arteries  (Eig.  58)  the  fore- 
arm, neck,  femoral,  and  aortic  regions  were  studied  skiagraph- 
ically.    Nowhere  did  the  plates  show  any  indications  of  degenera- 


CHEST 


97 


tion  of  an  artery  except  on  the  forearm.  From  the  negative  state 
of  the  other  skiagraphs  the  conclusion  was  drawn  that  the  pa- 
tient's arteriosclerosis  was  confined  to  the  radial  and  the  anterior 
interosseous  arteries — a  limitation  that  harmonized  with  the  good 
general  condition  and  the  absence  of  palpitation,  dyspnoea,  and 
vertigo.  As  a  rule,  however,  the  sclerotic  process  is  first  recognised 
in  the  region  of  the  foot.  Whenever  patients  between  thirty  and 
and  sixty  years  of  age,  especially  if  they  are  addicted  to  smoking  or 
drinking,  complain  of  "  rheumatic  pains  in  the  lower  extremities," 
skiagraphic  examination  is  indicated. 

Sclerosis  and  Osseous  Degeneration  of  Veins. — The  pathological 
changes  in  the  veins  are  similar  to  those  observed  in  the  arteries, 


Fig.  58. — Arteriosclerosis. 


phlebosderosis  (fibrous  degeneration  of  the  tunica  intima)  being 
nearly  as  frequent  as  arteriosclerosis,  but  as  a  rule  being  of  a  lesser 
extent.  Calcareous  deposits  in  the  veins  are  sometimes  reported 
as  vein-stones,  or  phleboliths.  But  that  there  is  a  degeneration 
of  the  intima  which  shows  real  osseous  structures  seems  not  to 
have  found  any  attention.  Fig.  59  shows  the  presence  of  per- 
fect osseous  texture  in  the  saphenous  vein,  as  well  as  in  the  be- 
ginning of  its  ramifications,  in  a  lady  of  fifty-six  years.  Dr. 
Ludwig  Weiss,  of  New  York  City,  to  whom  the  author  is  indebted 
for  observing  the  case,  found  that  the  patient  had  suffered  from 
varicose  veins  of  both  lower  extremities  for  thirty  years.  There 
were  frequent  attacks  of  thrombophlebitis  followed  by  dilatation 


98 


THE    RONTGEtf    RAYS 


as  well  as  by  cicatrization,  the  latter  causing  the  signs  of  phlebitis 
obliterans  on  various  portions.  There  was  also  a  large  ulcer  from 
which  profuse  hemorrhage  had  taken  place  several  times. 


Fig.  59.— Osseous  Degeneration  of  the  Saphenous  Vein. 
«,  Internal  saphenous  vein— late  stage ;    b,  same — early  stage ;    c,  small  saphenous  vein. 

The  patient  suffering  continuously  from  more  or  less  pro- 
nounced inflammatory  condition,  and  consequently  from  oedema 
and  induration,  extirpation  of  the  varicous  areas  was  advised.    On 


CHEST 


99 


removing  them  the  author  found  a  number  of  thrombi  in  the 
dilated  veins  which  on  some  portions  resembled  aneurysmatic  sacs. 
The  hard  consistency  of  the  thickened  portions  induced  him  to 
make  them  the  object  of  skiagraphic  exposure.  The  anatomical 
information  obtained  from  such  skiagraphic  examination  seems  to 
be  of  practical  value.  Whenever  the  Rontgen  rays  show  the  presence 
of  osseous  degeneration,  it  is  obvious  that  the  much  favored  meth- 
ods of  using  massage,  which  is  so  effective  in  arteriosclerosis,  laced 
stockings,  elastic  bandages,  injections  into  the  circumvascular  tis- 
sues, or  ignipuncture  represent  not  only  futile,  but  directly  danger- 
ous efforts,  the  only  procedure  which  guarantees  recovery  being 
extirpation.  If  performed  under  strict  aseptic  precautions  the  risks 
of  the  operation  are  practically  nil.  The  diagnosis  of  the  presence 
of  osseous  degeneration  can  not  be  made  by  palpation,  the  indurated 
areas  not  appearing  different 
from  simple  fibrous  convolu- 
tions. Thus  the  Rontgen  rays 
are  the  only  means  to  give  ana- 
tomical evidence  before  opera- 
tion. 

Tumour  of  the  Mediasti- 
num.— As  to  type,  shape,  and 
size  of  any  mediastinal  tumour 
much  more  reliable  informa- 
tion can  be  obtained  by  skiag- 
raphy than  by  percussion.  In 
the  case  of  a  patient,  aged 
fifty-three  years,  the  symptoms 
of  oesophageal  stenosis  became 
apparent,  the  oesophageal 
sound  stopping  at  the  level  of 
the  fifth  dorsal  vertebra. 
Signs  of  cachexia  supervening, 
carcinoma  of  the  oesophagus 
was  thought  of,  and  the  ques- 
tion of  operative   interference 

arose.  The  skiagraph  showed  a  mediastinal  tumour  of  the  size  of 
a  newborn  child's  head  that  pressed  upon  the  oesophagus.  There- 
fore an  operation  was  not  expected  to  be  of  any  benefit.  The 
autopsy  verified  the  diagnosis  five  weeks  later. 


Fig. 


60. — Myelosarcoma    of   Thoracic 
Wall. 


100 


THE    EONTGEN    EAYS 


Tumours  of  the  Thoracic  Wall. — In  tumours  of  the  chest-wall 
(fibroma,  osteoma,  chondroma,  osteochondroma,  myelosarcoma, 
osteosarcoma,  etc.),  the  question  as  to  how  far  the  pleura  and  lungs 

are  involved  is  of  great 
importance,  and  may 
determine  whether  re- 
moval still  offers  any 
hope  or  benefit  for  the 
patient.  The  same  may 
apply  to  far  advanced 
cases  of  carcinoma 
mammae,  which,  thanks 
to  the  advances  of  sur- 
gery, are  rarely  seen  at 
the  present  time. 

A  case  of  sarcoma 
in  a  boy  of  seven  years 
is  illustrated  by  Fig. 
GO.  The  skiagraph  in- 
dicated that  the  intra- 
thoracic organs  were 
free.  The  correctness 
of  the  indication  was 
corroborated  at  the  op- 
eration. (The  micro- 
scopical examination, 
referred  the  patient  to 
tumour   to   be    a   myelo- 


FlG. 


61.— Perforating  Pyothorax  Resembling 
Solid  Tumour. 


who    kindly 
showed  the 


made  by  Dr.  L.  Fischer, 
the  author  for  operation, 
sarcoma.) 

Fig.  61  illustrates  the  case  of  perforating  pyothorax  in  a  child 
of  three  years  three  months  after  the  onset  of  the  disease.  The 
swelling  being  of  a  hard  nature  and  the  course  being  slow,  a 
tumour  was  suspected  first.  Of  course,  the  diagnosis  could  be 
well  made  without  skiagraphy,  still  it  was  interesting  to  note  the 
integrity  of  the  intrathoracic  organs  by  it. 

In  the  case  of  carcinoma  mamma;,  described  in  Chapter  XVIII 
on  Rontgen-Ray  Therapy,  the  beginning  metastasis,  which  was  the 
precursor  of  pleuritic  exudation,  was  also  shown  by  the  Rontgen 
method.  Thus  the  imminent  fatal  end  was  predicted,  although  the 
patient  still  felt  well  at  that  time. 


CHEST  101 

(Esophageal  Stenosis. — To  Localize  stenosis  of  the  oesophagus  a 
rubber  tube  containing  thin,  flexible  steel  wire  in  spiral  form  may 
be  used,  the  skiagraph  demonstrating  where  the  stoppage  of  the 
tube  occurs.  Most  patients,  however,  will  no!  tolerate  this  other- 
wise effective  procedure.  Fig.  62  illustrates  the  stoppage  of  a 
sound  at  the  point  of  stricture,  caused  by  carcinoma  of  the  'esoph- 
agus, in  a  man  of  fifty-eight  years.     Gastrostomy  was  performed, 


Fig.  62. — (Esophageal  Stenosis  Caused  by  Carcinoma. 

which  prolonged  the  life  of  the  patient  for  eighteen  months.  The 
Rontgen  method  permits  of  differentiation  between  real  stenosis, 
produced  by  pathological  changes  in  the  oesophagus  wall,  and  con- 


102 


THE    KOXTGEX    KAYS 


tractions,  such  as  may  be  found  in  hysteria,  caused  by  disturb- 
ances of  innervation. 

For  fluoroscopic  observation  it  is  advisable  to  administer  an 
opaque  substance,  like  subnitrate  of  bismuth  in  a  wafer.  The  tube 
is  adjusted  in  front   of  the  patient's   right    shoulder  in   such   a 

manner  that  the  chest  is  ir- 
radiated from  the  right  upper 
anterior  aspect  towards  the 
left  lower  posterior.  The  bis- 
muth (about  15  grains)  can 
be  seen  during  the  act  of 
swallowing  as  a  marked  shad- 
ow that  becomes  diffused  after 
a  few  seconds;  then  a  portion 
of  it  is  detected  in  the  area  of 
stenosis,  while  the  other 
oesophageal  parts  show  noth- 
ing abnormal.  In  carcinoma 
the  bolus  remains  at  the  seat 
of  the  stenosis. 

(Esophageal  diverticula  may 
be   recognised  by    introducing 
a   sound  the  end  of  which  is 
provided    with    a    rubber   bal- 
loon.    If  the  latter  is  inflated 
in    situ,    the    diverticulum    is 
shown     as    a    light    globular 
mass. 
In  a  patient  of  sixty-five  years  asthmatic  symptoms  were  in  the 
foreground.     Percussion  and  auscultation  showed  dulness  of  the 
left  side,  reaching  from  the  lower  border  of  the  third  rib  to  two 
inches  below  the  arch  of  the  ribs. 

There  was  a  slight  bruit,  but  no  visible  pulsation.  Degluti- 
tion was  slightly  interfered  with.  The  patient  was  thin,  but  appar- 
ently there  was  no  cachexia.  The  skiagraph  showed  a  tumour  oc- 
cupying nearly  the  entire  left  thoracic  cavity.  The  irregular 
outline,  together  with  the  absence  of  pulsation,  pointed  to  the  pres- 
ence of  a  solid  tumour.  The  autopsy,  made  two  months  later, 
showed  an  enormous  sarcomatous  degeneration  of  the  bronchial 
glands. 


Fig.  63. — Aortic  Aneurysm  Projecting 
into  the  Supraclavicular  Space. 


CHEST  103 

Aneurysm  of  the  Aorta. — Aortic  aneurysm  can  be  studied  by 

the  screen  as  well  as  by  skiagraphy.     In  the  case  of  an  Italian 


Fig.  64.— Aortic  Aneurysm  Showing  Improvement   after  the   Administra- 
tion of  Iodide  of  Potassium. 

labourer  a  pulsating  tumour  was  detected  at  the  left  infraclavicu- 
lar fossa    (Fig.  63).     The  diagnosis  aneurysm  of  the  subclavian 


104 


THE    HONTGEN    EAYS 


artery  had  been  made  and  ligation  advised.  In  the  meanwhile 
several  skiagraphs  were  taken  that  showed  the  presence  of  aortic 
aneurysm,  the  supraclavicular  tumour  being  only  a  portion  of  it. 
Shortly  after  iodide  of  potassium  was  administered  the  supra- 
clavicular tumour  disappeared  entirely.     The  size  of  the  aneurysm 

had  considerably  decreased,  as 
was  shown  by  the  skiagraph 
(Fig.  64).  In  harmony  with 
the  anatomic  diagnosis  is  the 
excellent  condition  of  the  pa- 
tient, who  has  now  been  un- 
der observation  for  three  years. 
It  should  be  borne  in  mind 
that  under  normal  circum- 
stances the  aorta  is  seen  in  the 
left  mediastinum  at  the  first 
intercostal  space.  A  sac-like 
bulging  of  the  arch,  showing 
considerable  pulsation  above 
this  space,  points  to  the  pres- 
ence of  aortic  aneurysm.  Ve- 
hement pulsation,  if  there  is 
no  sac-like  bulging,  points  to 
aortic  insufficiency. 

In  a  most  extraordinary 
case  of  aortic  aneurysm,  illustrated  by  Fig.  65,  it  was  possible  to 
demonstrate  not  only  complete  atrophy  of  the  sternum  down  to  the 
xiphoid  process,  and  of  the  sternal  portions  of  the  clavicle,  but  also 
the  overlapping  of  the  heart  over  the  parasternal  line  and  down- 
ward displacement  of  its  apex.  (Fig.  66.)  The  patient,  an  archi- 
tect, aged  thirty-nine  years,  German  by  birth,  single,  gave  the  fol- 
lowing family  history :  Father  died  suddenly  when  sixty-five  years 
of  age;  mother  also  died  suddenly  when  sixty.  His  only  brother 
died  of  typhoid  fever  at  twelve.     There  were  no  sisters. 

The  patient  denied  lues,  and  the  examination  verified  his  state- 
ment. Gout  and  chronic  nephritis,  as  well  as  any  erotic  excesses, 
were  to  be  excluded.  He  was  always  well  until  five  years  ago; 
then,  after  lifting  an  excessively  heavy  weight,  he  noticed  a  small 
protuberance  on  the  left  side  of  his  neck;  this  grew  constantly, 
invading  at  last  the  whole  anterior  surface  of  the  neck  and  the 


Fig.  65. — Enormous  Aortic  Aneurysm, 
Causing  Atrophy  of  the  Clavicles 
and  the  Sternum.     (Compare  Fig.  66.) 


CHEST 


105 


upper  portion  of  the  chest.    It  is  highly  probable  thai  the  exertion 
in  lifting  caused  an  enormous  increase  in  the  circulatory  pressure, 


followed  by  an  overextension,  and  probably  a  laceration  of  the 
tunica  intima  and  media. 

Shortly  after  this  he  was  admitted  to  a  hospital,  where  he  was 
treated  for  torticollis,  as  he  states,  for  five  weeks.  During  that 
period  slight  dysphagia  and  hoarseness  had  been  present.     He  re- 


106  THE    KONTGEN    RAYS 

covered  again  so  far  as  to  regard  himself  well  for  an  entire  year. 
Then  a  "  severe  attack  of  malaria  "  induced  him  to  seek  hospital 
treatment  again.  At  that  time  the  tumour  had  not  exceeded  the 
size  of  a  large  apple.  The  hoarseness  was  considerable  then. 
After  having  improved  again  he  left  the  hospital,  and  for  eighteen 
months  after  had  been  under  medical  treatment  occasionally. 
Then  he  began  to  suffer  from  slight  dizziness,  with  constriction  of 
the  throat  and  chest.     Slight  dysphagia  and  hoarseness  recurred. 

On  October  31,  1898,  when  the  patient  entered  St.  Mark's 
Hospital,  the  author  saw  him  for  the  first  time.  The  tu- 
mour had  reached  an  enormous  size,  then  extending  over  the 
sternum,  the  sternal  portions  of  the  clavicles,  and  the  whole  ante- 
rior surface  of  the  neck,  the  diameter  of  the  latter  portion  being 
7-|  inches  (see  Fig.  66).  The  constant  pressure  of  the  tumour  had 
caused  complete  atrophy  of  the  adjoining  osseous  structures,  so 
that  no  visible  trace  was  left  of  the  sternum  or  of  the  sternal  por- 
tions of  the  clavicles. 

The  examination  of  the  heart  both  by  percussion  as  well  as  by 
the  Rontgen  method  revealed  hypertrophy  of  the  left  ventricle. 
The  apex  beat  was  felt  in  the  sixth  intercostal  space  an  inch 
beyond  the  mamillary  line.  Above  the  jugulum  and  in  the  right 
parasternal  line  a  diastolic  as  well  as  a  systolic  murmur  was  no- 
ticed, the  latter  being  more  distinct  at  the  systole.  On  placing  the 
hand  gently  on  the  tumour  slight  vibration  could  be  felt. 

The  lungs  were  normal.  No  cough  was  present.  Sometimes, 
especially  after  any  muscular  exertion,  there  was  dyspnoea.  The 
respiration  was  20  to  the  minute,  the  pulse  78,  the  temperature 
oscillated  between  97°  and  98°  F.  The  pulse  of  the  right  radial 
artery  was  weaker  than  that  of  the  left,  and  lagged  behind  it  ap- 
preciably. There  were  no  signs  of  arteriosclerosis.  The  voice 
was  clear  and  its  resonance  simply  remarkable,  the  previously 
existing  hoarseness  undoubtedly  having  been  due  to  pressure 
paralysis  of  the  recurrent  nerve.  The  dysphagia,  caused  by  press- 
ure upon  the  oesophagus,  was  very  moderate  on  his  admission. 

The  subjective  disturbances  of  the  patient  were  then  insignifi- 
cant. He  had  a  fine  appetite,  and  had  attended  to  his  business 
for  the  preceding  fonr  weeks. 

The  pulsation  was  unusually  moderate  in  comparison  to  the 
large  size  and  hardness  of  the  tumour,  a  circumstance  which 
pointed  to  the  presence  of  abundant  coagulation.    It  must  also  be 


CHEST  107 

assumed  that  the  aortic  wall  formed  by  adventitia  and  the  abun- 
dant proliferation  of  connective  tissue  had  become  so  much  forti- 
fied that  the  blood  could  discharge  again  from  the  subadventitial 
sac  in  the  peripheral  portion  to  the  proper  vascular  channel.  To 
these  fortunate  circumstances,  the  coagulation  as  well  as  the 
patency  of  the  vascular  channel,  the  surprising  euphoria  may  be 
attributed. 

As  alluded  to  above,  the  skiagraph  shows  complete  atrophy  of 
the  sternum  down  to  the  xiphoid  process,  and  of  the  sternal  por- 
tions of  the  clavicles.  The  heart  overlaps  the  parasternal  line,  and 
its  apex  shows  a  slight  displacement  downward.  Its  oval  shape  is 
distinctly  recognisable,  and  is  well  demarcated  from  the  aneurysm, 
the  intrathoracic  extent  of  which  is  enormous.  Other  skiagraphs 
taken  by  the  author  show  the  aortic  arch,  which  is  not  as  well 
represented  in  the  otherwise  distinct  skiagraph   (Fig.  66). 

Thus  it  can  be  seen  that  often  more  reliable  information  as  to 
type,  shape,  and  size  of  intrathoracic  tumours  can  be  obtained 
by  skiagraphy  than  by  percussion.  There  can  be  no  doubt  that  the 
Eontgen  rays  enable  us  to  recognise  aneurysms  at  their  earliest 
stages,  so  that  frequently  a  series  of  prophylactic  measures  can  be 
taken  which  may  counteract  any  further  aneurysm  formation.  The 
therapy  being  under  perfect  control,  it  can  be  ascertained  whether 
under  treatment  either  improvement,  arrest,  or  still  further  expan- 
sion may  take  place. 

The  patient  had  been  subjected  to  Barwell's  diet  and  to  gelatin 
injections  after  the  manner  of  Lancereaux  for  two  months.  The 
injections  had  been  well  borne,  except  on  one  occasion,  when  a 
slight  rise  of  temperature  followed  and  persisted  for  three  days. 
During  that  period  the  patient's  general  condition  was  consider- 
ably affected.  There  could  be  no  doubt,  however,  that  the  tumour 
decreased  in  size ;  the  hoarseness  disappearing  entirely,  and  the  sub- 
jective condition  of  the  patient  being  much  improved. 

In  July,  1899,  the  patient  died  after  three  days  of  an  acute 
attack  of  pneumonia.  The  autopsy  showed  no  rupture  of  the  enor- 
mous sac,  but  suppuration  of  the  bronchial  glands,  probably 
caused  by  the  gelatin  injections.  The  specimen,  Fig.  67,  obtained 
at  the  autopsy  shows  the  correctness  of  skiagraphic  representation. 

Fracture  of  Ribs  and  Scapular  Neck. — Fig.  68  shows  fracture 
of  the  neck,  of  the  scapula,  and  of  the  second  and  third  ribs.  The 
diagnosis  of  these  simultaneous  injuries  was  not  made  because  the 


108 


THE    KONTGEN    KAYS 


swelling  caused  by  the  injury  seemed  to  be  a  part  of  the  effusion 
around  the  shoulder-joint.     The  swelling  perceived  there  was  also 


Fig.  67.— Heart  and  Aortic  Aneurysm.     (Compare  Figs.  65  and  66.) 


attributed  to  the  main  injury.     There  were  no  physical  signs  pres- 
ent, and  the  subjective  symptoms  consisted  in  pain  that  was  also 


CHEST 


109 


thought  to  be  caused  by  injury  of  the  shoulder.  The  slight  cough 
noticeable  now  and  then  was  erroneously  explained  by  bronchitis, 
from  which  the  patient  had  suffered  before  be  sustained  the  injury. 
The  recognition  of  the  nature  of  the  joint  injury  enabled  the  author 
to  reduce  the  fragment,   which  was  displaced  downward. 

Fractures  of  Dorsal  Vertebrae. — In  those  eases  in  which  a  clear 
skiagraph  of  fracture  of  the  dorsal  vertebrae  can  be  seen  red  (as  to 
technique  see  page  70),  the  type  of  fracture,  the  size  and  num- 


Fkactube  of  Scapula  and  Ribs. 


ber  of  the  splinters,  and  their  location  may  be  represented  so  well 
that  the  indications  for  the  mode  of  treatment  can  be  clearly  set 
forth.  After  a  general  view  is  obtained,  the  seat  of  the  injury  is 
skiagraphed  by  the  aid  of  the  diaphragm  in  order  to  obtain  struc- 
tural details.  If  there  is  only  slight  angular  displacement,  reduc- 
tion can  be  accomplished.  But  in  the  event  of  intraspinal  haemor- 
rhage and  when  bone-fragments,  driven  into  the  canal,  press  upon 
the  cord,  operative  interference  is  required.  In  children,  of  course, 
the  best  reproductions  are  obtained,  one  minute's  exposure  gen- 
erally being  sufficient. 


110  THE    RONTGEN    EAYS 

Under  the  application  of  the  Kontgen  rays  the  results  of  oper- 
ations which  formerly  had  been  confined  to  exploration  have  be- 
come much  more  encouraging.  The  field  of  operation  being  out- 
lined by  the  skiagraph,  the  modus  operandi  can  be  determined 
beforehand.  While  at  one  time  it  was  deemed  advisable  to  expose 
a  large  portion  of  the  spinal  column  in  order  to  ascertain  that  every 
possible  injury  had  really  been  reached,  now  all  the  operative  pro- 
cedures can  be  carried  on  under  the  indication  of  the  rays  with 
ease  and  security,  even  the  length  of  the  incision  necessary  for  the 
removal  of  bone  splinters  being  suggested  by  the  skiagraph. 

It  is  surprising  that  surgeons,  who  find  it  most  natural  to  re- 
lieve, by  immediate  operation,  brain  pressure  caused  by  a  depressed 
fracture  of  the  skull,  should  hesitate  to  perform  the  similar  opera- 
tions upon  the  spinal  column.  Nothing,  indeed,  is  more  natural 
than  reduction  or  removal  of  a  fragment  pressing  upon  the  spinal 
cord. 

As  to  scoliosis,  kyphosis,  and  lordosis,  it  may  be  said  that  their 
treatment  can  be  well  controlled  by  repeated  skiagraphic  obser- 
vations. 

Inflammatory  processes,  like  spondylitis,  can  be  differentiated 
from  fractures  of  the  spinal  column.  Tuberculous  foci  in  the  ver- 
tebra? are  also  demonstrable.  The  same  applies  to  osteomyelitis 
and  necrosis. 

Localization  of  bullets  in  the  thoracic  cavity  is  not  always  easy. 
The  temptation  to  extract  bullets  that  cause  no  disturbance  is 
greater  than  formerly,  a  fact  which  is  not  to  be  registered  among 
the  advantages  of  the  Eontgen  rays  (compare  page  95  on  Peri- 
carditis). 

Nowhere  is  the  necessity  of  careful  interpretation  of  skia- 
graphs so  important  as  in  thoracic  diseases.  It  is  utterly  impos- 
sible to  instruct  a  non-medical  skiagrapher  and  to  impress  upon 
him  the  necessity  of  emphasizing  certain  points.  If  the  physician 
does  this  work  himself  he  will  be  able  to  judge  much  better.  But 
even  then  a  great  deal  of  doubt  as  to  the  real  nature  of  an  abnor- 
mal shadow  may  exist.  The  scientific  physician  must  never  be 
tempted  to  tax  his  power  of  imagination,  but  must  base  his  diag- 
nosis on  all  the  methods  at  his  command,  of  which  the  Rontgen 
rays,  however,  form  an  integral  part. 


CHAPTER    IX 
ABDOMEN 

The  abdomen  is  best  fluoroscoped  while  the  patient  is  standing. 
Skiagraphy  is  done  either  in  the  abdominal  or  dorsal  position. 
Sometimes  an  examination  in  an  oblique  perspective  must  be 
added. 

The  value  of  abdominal  skiagraphy  is  greater  than  tbat  of  flu- 
oroscop}'.  The  study  of  the  various  abdominal  organs,  however, 
leaves  much  to  be  desired.  Considering  the  thickness  of  the  abdo- 
men, it  seems  natural  that  hard  tubes  should  be  employed  in  order 
to  obtain  sufficient  penetration.  But  their  great  disadvantage  is 
that  they  diffuse  the  rays  so  that  the  image  becomes  blurred.  On 
the  other  hand,  it  is  difficult  to  utilize  soft  tubes  because  they  do 
not  penetrate  the  abdominal  wall.  This  factor  will  be  discussed 
further  below.  The  solid  masses  of  the  liver  can  be  easily  repre- 
sented, but  the  intestinal  loops  are  only  occasionally  shown.  The 
intestinal  contents,  especially  those  of  the  transverse  colon,  are 
recognisable.  The  outlines  of  the  stomach  can  be  made  visible  by 
substances  impermeable  by  the  rays.  The  spleen  and  kidneys  are 
rarely  demonstrated  at  the  screen,  but  can  be  outlined  by  skiagra- 
phy. Below  the  shadow  of  the  liver,  especially  of  its  left  lobe,  the 
lower  ribs  are  clearly  seen.  The  triangular  shadow  of  the  psoas 
muscle,  from  the  beginning  at  the  twelfth  dorsal  vertebra,  must 
always  be  recognised. 

The  chief  practical  results  in  abdominal  skiagraphy  have  so 
far  been  obtained  in  the  representation  of  the  injuries  and  diseases 
of  the  lumbar  vertebras  and  of  concretions  and  foreign  bodies. 
Thus  fractures,  dislocations,  inflammatory  processes,  and  growths 
of  the  lumbar  vertebrae  can  be  diagnosed,  as  also  calculi  of  the 
kidneys,  ureter,  bladder,  prostate,  urethra,  gall-bladder,  and 
hepatic  ducts. 

Ill 


112 


THE    RONTGEN   RAYS 


LIVER 


/ 


The  liver  is  best  represented  with  the  patient  in  the  abdominal 
posture.  In  newborn  children  its  shadow  is  especially  well 
marked.  The  position,  size,  and  shape  may  give  valuable  infor- 
mation in  many  ob- 
scure hepatic  ailments. 
Subphrenic  Abscess. 
—  The  diagnosis  of 
subphrenic  abscess  is 
simplified  by  fluoro- 
scopy as  well  as  by 
skiagraphy,  the  space 
between  the  diaphragm 
and  the  lower  boun- 
dary-lines of  the  ab- 
scess showing  distinct- 
ly. If  the  patient  is 
seated  on  a  chair,  the 
screen  being  held  in 
front  of  the  thorax 
and  the  Rontgen  tube 
behind  him,  the  upper 
portion  of  the  diseased  side  must  appear  normal — that  is,  light. 
Below  this  area  a  dark  one  appears  which  indicates  the  diaphragm 
(Fig.  69,  d).  Below  the  diaphragm  a  very  dark  shadow  is  found 
if  fluid  is  present.  This  would  correspond  to  the  dark  area  indi- 
cated by  Fig.  69,  a. 

When  the  patient's  position  is  changed  the  dark  area,  indica- 
ting the  fluid,  also  changes.  Sometimes  there  is  an  accumulation 
of  gas  in  the  subphrenic  abscess.  Then  a  light  area  will  be  seen 
above  the  dark  shadow.  As  soon  as  the  patient  is  shaken,  the 
horizontal  line,  indicating  the  border-line  between  gas  and  fluid, 
becomes  wavy. 

In  the  recumbent  position  the  dark  area  is  shown  only,  even  if 
gas  be  present.      (As  to  further  information,  see  author's  mono- 
graph on  Subphrenic  Abscess,  Medical  Record,  February  15,  1896.) 
Total  transposition  of  the  viscera  was  well  represented  in  a  case 
depicted  in  the  Annals  of  Surgery,  May,  1899.     Never  before  has 


Fig.  69. — Subphrenic  Abscess. 


ABDOMEN  113 

cholecystectomy  for  cholelithiasis  beeen  performed  on  the  left  side, 
as  it  was  in  this  remarkable  instance. 

The  greatest  usefulness  of  the  rays  in  hepatic  diseases  is,  how- 
ever, displayed  in  the  recognition  of  cholelithiasis. 

Cholelithiasis. — Gall-stones  have  not  been  skiagraphed  until 
recently.  It  was  the  privilege  of  the  author  to  show  the  first  undis- 
puted skiagraph  of  gall-stones  in  the  living  subject  at  a  meeting  of 
the  New  York  County  Medical  Association  in  October,  1899. 

As  emphasized  above,  the  diffusion  of  the  rays,  especially  in 
the  liver,  is  the  main  obstacle.  The  use  of  the  diaphragm  obvi- 
ates this  to  a  certain  extent,  but  not  sufficiently  for  the  pur- 
pose. The  harder  the  tube,  the  better  the  penetration,  but  the 
greater  the  diffusion  of  the  rays.  If  there  be  little  diffusion,  the 
bones  may  be  represented  well,  but  the  biliary  calculi  are  penetrated 
by  the  rays  to  such  an  extent  that  they  cast  no  shadow  on  the  plate, 
unless  there  should  be  a  large  amount  of  calcium,  which  is  rare. 

It  is  obvious,  therefore,  that  the  representation  of  biliary  cal- 
culi had  to  be  expected  from  a  soft  tube,  or  at  least  from  a  tube 
the  vacuum  of  which  stands  at  the  border-line  between  softness 
and  medium  hardness.  Such  tubes  show  the  osseous  tissues 
faintly,  a  fact  which  can  be  readily  observed  in  all  the  successful 
eases  of  the  author. 

Fig.  70  is  a  striking  illustration  of  this  fact.  It  represents  the 
case  of  a  woman  of  sixty-eight  years  whose  skiagraph  shows  several 
biliary  calculi  distinctly,  while  others  are  faintly  reproduced. 
Cholecystostomy,  performed  on  the  following  day  by  the  author, 
revealed  the  presence  of  231  small  calculi  and  one  larger  stone 
which  was  arrested  in  the  common  duct,  thus  having  prevented  the 
passage  of  the  smaller  sized.  The  distinctness  with  which  the  ribs 
are  reproduced  proves  that  the  vacuum  of  the  tube  employed  was 
too  high,  wherefore  it  permeated  the  calculi  which  were  situated 
directly  underneath  the  focus,  while  those  around  it  are  not  so 
well  penetrated. 

There  is  one  advantage  in  the  skiagraphy  of  the  contents  of 
the  gall-bladder  over  those  of  the  kidney — viz.,  the  possibility  of 
bringing  the  plate  very  near  the  area  to  be  skiagraphed,  the  inter- 
vening tissues  being  a  great  deal  thinner  than  in  the  renal  region. 

Various  Types  of  Biliary  Calculi. — The  results,  of  course,  are 
to  a  great  extent  dependent  on  the  chemical  composition  of  the 
biliary  calculi,  which  is  far  more  complex  than  that  of  urinary 
9 


114 


THE    RONTGEN    RAYS 


concretions.     All  the  different  types  of  calculi    (Fig.   71)    were 
skiagraphed  by  the  author  (Fig.  72)   (see  "On  the  Detection  of 


Fig.  70.— Concretions  in  the  Hepatic  Ducts. 

Calculi  in  the  Liver  and  G-all-bladder,"  New  York  Medical  Journal, 
January  20,  1900).  By  this  procedure  he  obtained  a  visual  com- 
parison of  their  impermeability.  The  same  calculi  were  irradiated 
then  through  the  living  body,  thus  practically  demonstrating  the 
difference  in  translucency  (Fig.  73). 

The  common  biliary  calculi,  the  most  frequent  type,  are  found 
to  be  quite  permeable  to  the  rays,  and  therefore  produce  only  a 
light  shadow.  If  present  in  large  numbers,  the  shadow  is  some- 
what more  conspicuous  (Figs.  71,  72,  and  73,  No.  2).  Calculi  com- 
posed of  pure  cholesterin  are  less  permeable  than  those  of  the  com- 
mon type,  and  show  a  slightly  more  distinct  shadow  (see  No.  5). 

The  stratified  cholesterin  calculi,  on  account  of  their  admix- 
ture with  calcium,  show  much  less  permeability,  and  therefore  pro- 


ABDOMEN 


115 


cluce  a  distinct  skiagraph  (Nos.  1  and  12).  The  mixed  bilirubin 
calculi,  which  contain  traces  of  copper  and  iron,  in  addition  to  the 
bilirubin-calcium,  are  less  permeable  than  all  the  former  varieties, 
and  consequently  give  a  very  distinct  shadow  (  No.  6).  The  same 
applies  to  the  pure  bilirubin-calcium  calculi. 

Calculi  composed  of  pure  bilirubin-calcium,  on  account  of  their 
mixture  of  calcium,  show  a  larger  degree  of  permeability,  and  their 
outlines  can  be  nearly  as  distinctly  shown  as  those  of  the  hiliruhin- 
calcium  calculi  (No.  7).  But  with  a  good  tube  even  the  more 
translucent  calculi  are  sometimes  represented.  Recently,  calculi 
that  were  only  the  size  of  a  pinhead  have  been  shown  in  the  gall- 
bladder.    Calculi  of  the  hepatic  ducts  have  also  been  represented. 

These  results,  which  could  formerly  hardly  be  hoped  for,  are 
attributed  mainly  to  the  excellent  quality  of  the  soft  tubes  used, 
which  permitted  of  the  employment  of  a  strong  current.  In  fact,  the 
most  important  requisite  for  skiagraphic  success  in  such  delicate 


Pig.  71. — Various  Types  of  Biliary  Calculi.     (Compare  Figs.  7:2  and  73.) 


work  is  a  strongly  built  tube  of  a  low  vacuum  in  connection  with 
a  large  Ruhmkorff  coil. 

It  has  been  found  that  the  soft  tubes  used  for  the  reproduction 
of  biliary  calculi  display  their  best  energy  so  long  as  they  are 


116 


THE    RONTGEN    RAYS 


comparatively  new.  Later  on  they  show  less  contrast,  just  like 
very  hard  tubes,  even  if  provided  with  an  attachment  for  regener- 
ation.    If  the  tube  works  well  from  the  beginning,  the  average 


time  of  exposure  should  be  about  four  minutes  in  thin  individ- 
uals, and  about  six  in  stout  cases. 

The  position  of  the  patient  while  being  skiagraphed  is  also  an 


ABDOMEN 


117 


important  factor.    Ho  should  lie  on  his  abdomen  with  about  three 
pillows  underneath  his  clavicles,  as  the  elevation  produced  permits 


CM 


00 


00 


CM 


m 


the    protrusion    of   the    gall-bladder,    thus    bringing    the    calculi 
nearer  the  photographic  plate.    The  approximation  is  increased  by 


118 


THE    KONTGEN    KAYS 


turning  the  body  slightly  to  the  right  and  raising  the  left  side. 
A  diaphragm  should  always  be  used  (Fig.  74). 

A  pencil  mark  should  be  made  on  the  back  to  correspond  to 
the  site  of  the  gall-bladder  in  front. 

In  order  to  exclude  any  possible  source  of  error  from  intestinal 


Fig.   74. 


-Position  fok   Skiagraphing  Region   of   the   Gall-bladder  by  the 
Aid  of  Author's  Diaphragm. 


contents,  the  bowels  must  be  thoroughly  evacuated  before  irra- 
diation. 

By  using  this  method  the  size,  shape,  and  diameter  of  the 
gall-stones  can  not  only  be  determined  in  suitable  cases,  but  they 
can    also    be    localized.      The    importance    of    knowing    whether 


ABDOMEN  119 

there  are  also  calculi  in  the  liver  besides  those  present  in  the  gall- 
bladder needs  no  discussion. 

Intrahepatic  Calculi. — The  presence  of  calculi  in  the  liver  tis- 
sue explains  why  cholelithiasis  is  often  only  partially  cured  by 
cholecystotomy.  This  fact  shows  why  calculi  have  sometimes  sur- 
prised the  surgeon,  who  has  thoroughly  evacuated  the  gall-blad- 
der, by  their  appearance  a  few  days  after  the  cholecystotomy. 
That  in  cholelithiasis  sometimes  hundreds  of  calculi  are  contained 
in  the  hepatic  ducts  is  a  well-known  fact,  but  why  calculi  appeared 
after  cholecystotomy  has  heretofore  been  explained  only  on  the 
autopsy  table.  (See  author's  monograph:  When  shall  we  Operate 
for  Cholelithiasis?  in  the  New  York  Medical  Journal,  May  8, 
1897.) 

Practical  Value  of  Skiagraphy  of  Biliary  Calculi. — It  is  evi- 
dent that  a  positive  skiagraph  renders  exploratory  laparotomy  for 
suspected  cholelithiasis  unnecessary.  It  can  be  ascertained  by 
subsecpicnt  exposures  whether  any  calculi  have  been  dislodged  or 
whether  some  have  escaped.  If  they  are  of  very  large  size,  their 
removal  by  other  than  surgical  means  would,  of  course,  not  be 
expected.  So  the  question  whether  or  not  operation  is  advisable 
in  cholelithiasis  may  be  settled  by  the  Rontgen  rays.  When  only 
small  stones  are  present,  there  is  a  chance  for  medical  treatment. 
When  stones  are  found  too  large  to  pass  the  common  duct,  medical 
treatment  can  only  be  palliative,  and  cholecystotomy  should  be 
performed  as  soon  as  the  calculi  prove  to  be  a  source  of  irritation 
and  danger. 

Deficiencies  of  the  Method. — It  is  appreciated  that  the  method 
given  for  diagnosing  biliary  calculi  is  incomplete  and  needs  fur- 
ther modification  and  improvement,  as  there  are  many  delicate 
technical  details  on  the  correct  appreciation  of  which  success 
depends.  Skiagraphy  of  biliary  calculi  is  not  so  perfect  a  diagnos- 
tic method  as  that  of  renal,  ureteral,  and  vesical  calculi.  While 
a  negative  result  in  the  case  of  suspected  urinary  calculi  can  now 
be  pretty  safely  taken  as  evidence  of  the  absence  of  calculi,  pro- 
vided the  skiagraph  is  blameless,  the  same  cannot  as  yet  be  said  of 
biliary  calculi.  But,  on  the  other  hand,  it  can  safely  be  asserted 
that  even  a  faint  skiagraphic  reproduction  of  biliary  calculi 
proves  their  presence  to  the  expert  reader.  With  increased  knowl- 
edge and  improved  technique  the  skiagraphic  reproduction  of  bil- 
iary calculi  will  become  a  great  deal  easier. 


120 


THE    RONTGEN    RAYS 


The  outlines  of  the  gall-bladder  are  often  shown  if  there  is 
cholelithiasis.     On  account  of  the  long-continued  irritation,  the 


Fig.  75. — Biliary  Calculi  (two  of  them  are  faceted). 

bladder  walls  become  thick  and  fibrous  and  consequently  less  per- 
meable to  the  rays. 

Fig.  75  represents  two  large  faceted  gall-stones  in  the 
gall-bladder,  and  four  in  the  vicinity,  one  probably  in  the  cystic 
duct  and  three  in  the  intrahepatic  ducts.  Their  elliptic  shape, 
their  size,  and  their  diameter  can  be  well  recognised.  The  patient, 
a  man  of  forty  years,  is  still  in  the  possession  of  his  stones,  which 
cause  only  occasional  and  very  slight  disturbance,  so  that  the 
author  did  not  feel  justified  in  persuading  him  to  submit  to  an 
operation.  The  patient  is  the  brother  of  the  woman  whose  large 
biliary  calculus  was  removed  from  the  left  side  (see  p.  112)  ;  from 
a  sister  of  this  patient  the  writer  also  removed  two  large  biliary 
calculi.  There  are  ten  members  of  this  family  in  whom  cholelithi- 
asis could  be  diagnosed. 

Fig.  76  shows  a  large  and  two  small  biliary  calculi  in  a  man 
of  forty-five  years.    In  this  case  the  large  gall-stone  is  overshad- 


ABDOMEN  121 

owed  by  the  rib.     If  the  tubal   vacuum  had  been  slightly  lower, 
the  outlines  would  probably  also  have  been   more  distinct. 

Fig.  77  shows  a  solitary  calculus  faintly,  while  smaller  intra- 
hepatic calculi  are  represented  distinctly.  Cholecystotomy  per- 
formed by  the  author  a  few  days  after  exposure  proved  the  pres- 


Fig.  76. — Three  Biliary  Calculi. 


ence  of  a  large  calculus  (Fig.  78)  in  the  gall-bladder.    No  evidence 
was  found  of  the  others  in  the  ducts.    This  must  be  explained  by 


122  THE    RONTGEN    EAYS 

their  intrahepatic  domicile,  which  could  not  be  exposed.  In 
favour  of  this  assumption  was  the  extremely  severe  cholangioitis 
from  which  the  patient  suffered  after  the  operation.     The  skia- 


Fig.  77. — Solitary  Biliary  Calculus. 

graph  shows  the  extracted  stone  translucent,  as  it  consisted  mainly 
of  cholesterin. 

Fig.  79  shows  the  presence  of  a'  large  number  of  calculi  of 
various  sizes. 

It  is  interesting  to  observe  that  a  woman  of  thirty-seven  years, 
whose  calculi  were  skiagraphed  three  years  ago,  was  re-examined 
recently.  Three  skiagraphs  taken  at  different  times,  in  different 
positions,  showed  a  negative  result.  The  patient  had  submitted 
to  diet,  much  better,  and  the  regular  administration  of  Carlsbad 
Muehlbrunn  for  more  than  a  year,  and  the  result  was  that  the 
tumour  in  the  region  of  the  gall-bladder  had  disappeared.  Her 
general  condition  had  also  improved  accordingly,  and  no  colicky 
attacks  were  noted  during  the  last  eighteen  months.    One  may  feel 


ABDOMEN 


123 


justified  in  believing  that  the  negative  skiagraph  confirmed  the 
impression  that  the  stones  had  passed  away. 


KIDNEYS 

The  kidney  must  be  skiagraphed  in  the  dorsal  position.  Tubes 
of  moderate  hardness  are  best  for  their  skiagraphy  representation ; 
very  hard  tubes  penetrate  the  organs  and  leave  no  shadow.  Renal 
fluoroscopy  cannot  be  relied  on  with  our  present  means. 

Hydronephrosis  and  echinococeus  cyst  can  be  represented  under 
favourable  circumstances.  The  greatest  usefulness  of  the  rays  in 
renal  disease,  however,  is  displayed  in  diagnosticating  concretions. 
Great  credit  is  due  to  Mclntyre  for  having  been  the  first  to  skia- 
graph renal  calculi.  Soon  afterward  Twain,  Thyne,  Kummell, 
and  Ringel,  as  well  as  the  author,  obtained  distinct  skiagraphic 
representations  of  nephrolithiasis. 

Naturally  such  calculi  can  be  represented  best  which  consist 
of  hard  and  firm  material,  like  oxalates,  while  the  more  penetrable 
phosphates  cast  an  indistinct  shadow, 
and  the  translucent  urates  hardly  at  all. 
Thus  we  learn  that  the  success  of  ski- 
agraphy in  calculi  of  the  urinary  tract 
depends  largely  on  the  chemical  compo- 
sition of  the  calculi,  and,  consequently, 
on  their  greater  or  lesser  opacity.  Still, 
with  the  aid  of  the  diaphragm  more  or 
less  marked  shadows  even  of  the  urates 
are  obtained.  The  beautiful  work  of 
Abbe,  Bevan,  and  Leonard,  all  of  this 
country,  furnish  striking  illustrations 
of  the  immense  progress  of  this  young 
science  in  the  short  space  of  a  few  years. 

As  to  the  technique  of  the  skiagra- 
phy of  renal  concretions  many  of  the 
principles  emphasized  in  connection 
with  biliary  calculi  hold  good    (see  p. 

113).  Considering  the  diffusion  of  the  rays,  the  use  of  a  dia- 
phragm is  indispensable.  Thus  even  small  calculi  may  be  repre- 
sented. 

In  regard  to  their  chemical  composition,  it  should  also  be  re- 


Fig.  78.— Biliary  Calculus. 


124 


THE    RONTGEN    EAYS 


membered  that  a  calculus  may  consist  of  different  salts.  In  one 
of  the  author's  cases  five  layers  were  found,  the  nucleus  and  third 
layer  consisting  of  calcium  carbonate,  its  branches  of  a  combina- 


Fig.  79.— Numerous  Biliary  Calculi  in  much  Distended  Gall-bladdek. 


tion  of  calcium  carbonate  and  triphosphate,  and  the  outer  crystal- 
line layer  of  carbonate  of  magnesium  and  ammonium. 

Under  such  circumstances  the  nucleus  will  be  more  marked 
if  a  tube  of  moderate  hardness  is  used,  while  the  branches  will  be 


ABDOMKX  125 

more  conspicuous  if  a  soft  one  is  employed.  As  a  rule,  tubes 
should  be  chosen  that  are  slightly  harder  than  those  used  for  skia- 
graphing  biliary  calculi.  The  time  of  exposure  should  be  four 
minutes  in  thin  and  about  six  minutes  in  stout  individuals.  A 
good  skiagraphic  representation  of  nephrolithiasis  renders  an  ex- 
ploratory incision  unnecessary.  It  will  settle  the  question  of  the 
presence  or  the  absence  of  concretions,  and  in  case  an  operation  is 
indicated,  it  will  give  valuable  hints  as  to  the  technique. 

While,  as  has  been  said  above,  a  negative  result  cannot  be  re- 
lied upon  in  a  case  of  suspected  cholelithiasis,  a  good  skiagraphic 
plate  which  does  not  show  the  presence  of  renal  calculi  may 
safely  be  regarded  as  diagnostic-ally  conclusive.  Kiimmell  veri- 
fied the  skiagraphic  diagnosis  in  all  cases,  the  operation  proving 
its  correctness  sixteen  times  and  the  autopsy  twice.  The  charac- 
teristics of  a  reliable  renal  skiagraph  are  that  it  shows  the  out- 
lines of  the  psoas  muscle  and  the  lower  ribs  and  the  structure  of 
the  transverse  processes.  If  they  show  distinctly,  a  calculus  which 
is  not  smaller  than  a  pea  would  necessarily  also  leave  its  shadow 
on  the  plate.  Very  small  concretions  may  be  overlooked.  But  if 
these  marks  are  not  distinctly  shown,  the  negative  plate  must 
never  be  relied  upon. 

When  we  bear  in  mind  the  high  mortality  of  nephrolithiasis 
at  a  late  stage  and  how  many  lives  will  be  saved  by  early  opera- 
tion, the  importance  of  early  recognition  of  the  calculi  becomes 
evident. 

Nephrolithiasis  as  well  as  cholelithiasis  is  often  confounded 
with  appendicitis.  It  is  in  the  interest  of  the  patient  as  well  as  in 
that  of  the  medical  profession  that  differentiation  is  made  before- 
hand, instead  of  removing  the  appendix  first  and  then  being  told,  by 
the  continuation  of  the  painful  attacks,  and  finally  by  the  passing 
of  a  calculus,  that  there  was  an  error  loci  as  far  as  the  field  of  oper- 
ation is  concerned.  (Compare  author's  monographs  on  Appendi- 
citis, New  York  Medical  Journal,  November  14,  1898,  and  Wiener 
klinische  Eundschau,  August  2-16,  1903.) 

Fig.  80  shows  a  large  renal  calculus  in  a  man  of  forty-two 
years. 

It  should  also  be  borne  in  mind  that  palpation  may  fail  to  re- 
veal calculi  of  moderate  size.  In  such  cases  fluoroscopy  during  the 
operation  is  indicated.  A  special  fluoroscopic  arrangement  must 
be  prepared  for  such  occasions  (compare  p.  39).     The  fluoroscope 


126  THE    KONTGEN    KAYS 

should   be  of  small   size,   and  must  be  surrounded   with   sterile 
gauze. 

In  interpreting  skiagraphs  taken  for  suspected  nephrolithiasis, 
it  should  be  borne  in  mind  that  under  extraordinary  circumstances 
biliary  calculi  may  be  taken  for  calculi  of  the  right  kidney.  It 
may  be  said,  however,  that  as  a  rule  the  shape  of  biliary  calculi  is 
different  from  that  of  renal  concretions;  the  former  are  located 
higher  up,  and  do  not  show  so  clearly  from  the  back  as  they  do 
from  the  front.  Of  course,  in  those  cases  in  which  the  shape  of 
the  kidney  is  recognized,  the  shadow  of  the  renal  calculus  will 
hardly  be  misinterpreted.     In  case  of  doubt,  an  oblique  exposure 


Fig.  80. — Renal  Calculus. 

may  show  a  renal  calculus  in  the  back,  while  gall-stones  would 
appear  more  in  front. 

The  shape  of  renal  calculi  is  characteristic.  Their  contours 
are  generally  well  marked.  They  are  usually  of  an  irregular  shape 
unlike  that  in  biliary  calculi,  projections  often  being  present.  As 
a  rule,  the  renal  calculi  are  detected  around  the  two  last  ribs, 
about  2  inches  laterally  from  the  spinal  column.  The  clinical 
symptoms  should  also  be  properly  considered  before  conclusions 
are  drawn.  Just  as  in  cholelithiasis,  the  skiagraphic  proof  of  the 
presence  of  small  calculi  shows  that  much  is  to  be  hoped  for  from 
medical  treatment,  while  the  removal  of  large  calculi  cannot  be 
expected  by  any  other  than  surgical  means. 


ABDOMEN  127 

The  distance  of  the  tube  from  the  patient's  skin  in  skiagraphic 
representation  of  the  kidney  should   be  aboul    I   inches.     Several 

exposures  are  always  necessary.  The  preliminary  exposure  should 
comprise  a  surface  the  border-line  of  which  is  formed  by  the  crista 
ossis  ilei  and  the  eleventh  rib  on  one  side  and  by  the  spinal  col- 
umn on  the  other.  This  area  is  marked  on  the  patient's  plate 
for  future  comparison.  If  the  signs  of  a  calculus  are  found  on 
the  preliminary  plate,  the  diaphragm  is  placed  above  the  indicated 
area  for  better  differentiation.  Just  as  in  skiagraphs  of  biliary 
calculi,  it  is  not  required  that  the  outlines  of  renal  concretions 
should  be  so  distinct  that  they  can  be  reproduced  in  print.  By 
keeping  off  the  daylight  it  is  often  possible  for  the  expert  reader 
to  detect  a  calculus  which  escaped  superficial  inspection.  The  plate 
must  be  studied  from  various  directions,  and  must  not  only  be  held 
in  the  vertical,  but  also  in  the  horizontal  position.  Thus  the  faint 
contours  of  a  stone  are  sometimes  shown  which  were  overlooked 
by  ordinary  examination.- 

The  advice  of  an  operation  should  never  be  based  upon  the 
result  of  a  Rontgen  examination  alone.  It  cannot  be  repeated 
too  often  that  the  Rontgen  rays  do  not  represent  a  substitute  of 
our  old  standard  methods,  but  are  a  most  valuable  addition  to 
them.  Careless  interpretations  of  indistinct  skiagraphs  will  only 
discredit  it. 

The  clinical  and  chemical  methods  of  examination  should  al- 
ways be  employed  in  the  first  place.  They  must  work  hand  in 
hand  with  skiagraphy  then.  The  presence  of  blood  and  pus-cor- 
puscles in  the  urine,  if  not  explained  by  infectious  diseases  or  by 
vesical  affections,  demands  a  skiagraphic  exposure. 

Skiagraphy  of  biliary  as  well  as  of  renal  calculi  taxes  the 
patience  of  the  operator  greatly.  Whoever  does  not  possess  this 
virtue  would  better  concentrate  his  activity  upon  other  useful 
fields.  Sometimes  it  takes  two  hours  of  uninterrupted  work  to 
obtain  a  satisfactory  reproduction. 

Concretions  in  Ureter  and  Bladder. — Ureteral  and  vesical  cal- 
culi can  be  skiagraphed  after  the  same  principles.  Difficulties  arise 
only  in  stout  individuals.  A  vesical  calculus  shows  best  with  the 
subject  in  the  recumbent  position,  the  centre  of  the  tube  to  be 
directed  to  the  upper  margin  of  the  symphysis  pubis.  Any  vesical 
calculus,  except  it  be  very  small,  will  surely  be  evident  on  a  good 
skiagraph.     A  good  skiagraph  of  the  vesical  region  must  show  the 


128 


THE    BONTGEN    RAYS 


structures  of  the  coccyx  well.  By  oblique  irradiation  the  shadows 
of  the  calculi  are  generally  found  just  below  those  of  the  coccyx. 
An  oblique  exposure  should  always  be  made  besides,  because  it  may 
show  whether  the  stone  is  free  or  encysted.  If  the  patient  bends 
lightly  forward  in  the  lateral  position,  the  calculus,  if  free,  sinks 

towards  the  anterior 
vesical  wall  and  be- 
comes conspicuous  di- 
rectly behind  the  an- 
terior abdominal  wall. 
If  it  is  not  free,  it 
usually  shows  far  back 
towards  the  sacrum, 
since  encysted  calculi 
are  nearly  always  at- 
tached to  the  poste- 
rior vesical  wall.  If 
the  stone  is  of  very 
large  size,  or  if  a  great 
number  of  them  are 
present,  the  whole 
vesical  space  is  filled 
up  and  displacement 
is  not  apt  to  occur. 
So  far  as  the  diagnosis  of  the  number,  shape,  and  position  of  vesi- 
cal calculi  is  concerned,  the  Eontgen  rays  afford  a  more  valuable 
means  than  the  cystoscope.  The  time  of  exposure  should  be  about 
three  minutes.     A  tube  of  medium  hardness  is  best. 

Foreign  bodies,  such  as  hair-pins  and  similar  objects,  which 
entered  the  bladder  by  the  urethral  route,  must  be  frequently 
looked  for  by  skiagraphic  examination.  They  are  soon  surrounded 
by  incrustations  which  make  their  recognition  so  much  easier. 

In  children  the  representation  of  vesical  calculi  is  especially 
easy,  an  exposure  of  a  minute's  duration  generally  being  sufficient. 
Fig.  81  shows  the  bisected  halves  of  a  calculus  extracted  from 
the  bladder  of  a  boy  of  six  years.  It  has  an  elliptic  shape,  its 
length  being  9  and  its  width  6  centimetres.  Although  the  restless 
patient  moved  considerably,  the  displacement  amounting  to  a 
whole  inch,  the  shadow  of  the  calculus  can  be  distinctly  recognised 
on  the  plate  (Fig.  82).    It  appears  as  consisting  of  two  shadows, 


Fig.  81. — Bisected  Halves  of  Vesical  Calculus, 
Illustrated  by  Pigs.  82  and  83. 


ABDOMEN"  120 

however.     The  exposure  only  lasting  half  a  minute,  the  density 
of  the  bones  also  appears  weak. 

A  later  exposure,  Fig.  83,  shows  the  calculus  very  distinctly. 
An  oblique  exposure  showed  the  calculus  faintly.  It  seemed  to  be 
situated  above  the  coccyx.     It  was  assumed  that  it  was  impacted 


Fig.  82.— Vesical  Calculus.     (Compare  Figs.  81  and  83. ) 

there,  because  no  displacement  could  be  noticed  when  the  position 
was  changed.     Suprapubic  cystotomy  corroborated  the  correctness 
10 


130  THE    RONTGEN   RAYS 

of  this  assumption.     The  mucous  membrane  of  the  bladder  had 
overlapped  the  calculus  to  a  great  extent,  so  that  its  removal  from 


Fig.  83. — Vesical  Calculus  (Compare  Figs.  81  and  82). 

the  deep  pouch  was  connected  with  considerable  technical  diffi- 
culties. 

Fig.  84  shows  a  large  vesical  calculus  in  a  man  of  seventy  years. 

Ureteral  calculi  are  skiagraphed  after  the  same  principles. 


ABDOMEX 


131 


Whether  the  concretions  are  in  the  bladder  or  in  the  ureter 
is  sometimes  difficult  to  ascertain.  Kryoscopy,  cystoscopy,  and 
ureteral  probing  is  a  most  valuable  adjunct  in  such  cases.  The 
combined  examination  ascertains  whether  there  is  general  func- 
tional disturbance,  or  bilateral  or  unilateral  stone-formation.  It 
also  shows  whether  simultaneous  lesions  of  a  different  nature  exist 
besides. 

Foreign  Bodies  in  the  Abdomen. — Metallic  bodies  in  the  abdo- 
men are,  of  course,  easily  demonstrated.     As  modern  surgery  makes 


Fig.  84. — Vesical  Calculus  in  a  Man  of  Seventy  Years. 


immediate  laparotomy  imperative  in  all  bullet  wounds  of  the  abdo- 
men, it  may  be  realized  how  important  is  skiagraphic  localization. 
Tacks  and  needles  can  be  easily  localized.  The  popularity  of  the 
Murphy  button  gives  frequent  opportunities  to  observe  its  char- 
acteristic shadow  while  it  travels  through  the  intestinal  tract. 


132 


THE    RONTGEN    RAYS 


Tumours  of  the  Stomach  are  representable  only  if  their  texture 
shows  a  considerable  degree  of  density.  The  outlines  of  the  stom- 
ach can  be  mapped  out  if  the  viscus  is  filled  with  salts,  such  as  sub- 
nitrate  of  bismuth,  that  are  impermeable  to  the  rays.  The  intro- 
duction of  a  soft  rubber  tube  the  lumen  of  which  is  filled  with 
mercury  is,  however,  preferable.  A  rubber  tube  containing  a  thin, 
flexible  steel  wire  in  a  spiral  form,  as  advised  by  the  author,  per- 
mits the  rapid  representation  of  the  outlines  of  the  stomach.  The 
stoppage  of  this  tube  indicates  its  arrival  at  the  large  curvature  of 
the  stomach  and  further  propulsion  shifts  it  along  the  wall.  There 
the  steel  spiral  is  clearly  shown  by  the  skiagraph. 

Inflation  of  the  stomach  by  carbonic-acid  gas,  air,  or  a  mixture 
of  tartaric  acid  and  bicarbonte  of  soda  has  also  been  used  to  define 
its  outlines.  The  large  and  small  curvatures,  as  well  as  the  cardia, 
can  thus  be  represented.  The  infantile  stomach  is  especially 
fit  for  skiagraphic  representation.  In  selected  cases,  the  relations, 
especially  the  motions  of  the  spiral  wire,  can  be  studied  by  the 

aid  of  the  screen.    Tubes  of  medium 
hardness  should  be  chosen. 

The  different  phases  of  diges- 
tion can  be  studied  by  fluoroscopic 
as  well  as  by  skiagraphic  observation 
after  subnitrate  of  bismuth  is  swal- 
lowed. The  lower  animals  can  also 
be  utilized  for  that  purpose.  Frogs, 
mice,  cats,  or  guinea-pigs  may  be 
given  a  mixture  of  flour,  milk,  and 
bismuth.  Skiagraphic  exposures, 
repeated  every  twenty  minutes,  can 
then  be  studied  with  leisure. 

Spina  Bifida. — The  diagnosis  of 
the  various  types  of  spina  bifida  is 
facilitated  by  the  rays.  In  speak- 
ing of  this  malformation  in  general 
one  is  apt  to  think  only  of  its  cys- 
tic form  and  of  its  location  in  the 
lumbo-sacral  region.  But  besides  this  most  common  type  there 
are  several  others  which  require  to  be  distinguished  before  we 
can  choose  the  proper  therapy.  Thus  it  cannot  be  a  matter  of  indif- 
ference whether  there  is  a  so-called  simple  meningocele — in  other 


Fig.  85.— Spina  Bifida  (See  Fig.  86). 


ABDOMEN 


133 


words,  a  hernia-like  protrusion  of  the  pia,  containing  cerebral 
fluid;  or  a  myelomeningocele,  a  frequent  variety,  which  is  charac- 
terized by  the  spinal  cord 
expanding  itself,  like  the 
optic  nerve  in  forming 
the  retina,  around  the 
protrusion,  and,  together 
with  the  pia,  constitut- 
ing the  sac;  or  whether 
there  is  a  myelocysto- 
cele— that  is,  a  tumour 
caused  by  cystic  dilata- 
tion of  the  central  canal 
of  the  spine. 

It  is  also  important 
to  discriminate  whether 
the  tumour  is  situated 
in  the  cervical,  dorsal, 
lumbar,  or  sacral  region. 
If  situated  in  the  cervi- 
cal or  dorsal  region,  the 
cord  cannot  protrude 
into  the  hernial  sac,  as 
it  does  in  the  lumbar  or 
sacral  portion,  which  cor- 
responds to  the  end  of 
the  cord.  It  is  also  de- 
sirable to  know  whether 
there  is  a  hiatus  in  the 
spinal  column,  and  how 

extensive  it  may  be;  and,  furthermore,  whether  or  not  the  fluid 
contained  by  the  tumour  can  be  dislodged  into  the  spinal  canal. 

In  view  of  these  anatomical  distinctions,  it  will  be  easily  under- 
stood that  simple  meningocele  gives  the  best  chances  for  cure. 
Whether  injection  treatment  or  extirpation  should  be  preferred 
is  not  yet  agreed  upon  among  the  profession.  The  writer  remem- 
bers having  cured  three  or  four  cases  of  simple  meningocele  by 
repeated  aspiration,  followed  by  the  injection  of  a  few  grains  of 
a  10-per-cent  iodoform-glycerin  emulsion.  He  generally  prefers 
injection  to  extirpation,  provided  the  surface  of  the  skin  be  nor- 


FlG. 


. — Spina  Bifida,  showing    Hiatus  (See 
Pig.  85). 


134 


THE    RONTGEN    RAYS 


mal.     Of  course,  if  there  be  well-developed  gangrene,  or  even  any 
considerable  abrasion  of  the  epidermis,  then  septic  infection  of 


Fig.  87.— Spina  Bifida  (See  Fig.  88). 


the  cyst  wall  cannot  be  arrested  unless  immediate  and  extensive 
removal  is  undertaken. 

On  the  other  hand,  myelomeningocele  and  myelocystocele  offer 
a  less  favourable  prospect.     In  these  cases  the  injection  treat- 


ABDOUK.X 


135 


ment  is  always  a  failure.  I  J'  in  myelomeningocele  the  nerves  are 
freely  dispersed  in  the  sac,  the  area  medullaris  vasculosa,  after 
being  circumcised,  must  be  reduced  into  the  vertebral  canal,  and 
the  union  of  the  soft  tissues  above  must  be  reduced  in  the  same 


-Spina   Bifida,  illustrated   by  Fig.  87,  in   Anteroposterior  Pro- 
jection. 


way.     If  situated  in  the  lumbo-sacral  region,  the  preservation  of 
the  nerve  strings  is  of  but  little  importance. 

In  myelocystocele  the  reposition  should  be  made  in  the  same 
manner.    If  there  be  any  opening  in  the  bone,  protection  should  be 


136  THE    KONTGEN    EAYS 

sought  by  covering  it  with  a  strong  flap,  consisting  of  integument 
and  muscle. 

One  of  the  greatest  difficulties  encountered  in  the  treatment 
of  spina  bifida  is  that  its  various  types  cannot,  as  a  rule,  be  de- 
fined before  operation.  Between  meningocele  and  myelocystocele, 
indeed,  distinction  is  often  quite  impossible.  Sometimes  conclu- 
sions may  be  drawn  if  an  opening  of  the  bone  can  be  palpated,  or 


Fig.  89.— Rhachitic  Pelvis. 

if  a  portion  of  the  fluid  can  be  reduced  into  the  spinal  canal  by 
pressure.  Paralysis  of  the  lower  extremities,  of  the  rectum  and 
bladder  point  to  the  existence  of  myelomeningocele;  but  all  these 
signs  are  far  from  being  absolutely  reliable.  Considering  only 
this  one  point — that  in  meningocele  aspiration  should  be  tried 
first,  while  in  the  other  varities  extirpation  must  be  resorted  to — 
it  must  be  admitted  that  our  deficiency  in  scientific  knowledge 
makes  itself  rather  strongly  felt  as  regards  therapy.  Some  au- 
thors advise  opening  the  lower  portions  of  the  tumour  first,  in 
order  to  ascertain  whether  the  spinal  column  is  open,  as  in  myelo- 
meningocele, or  not,  as  in  meningocele.  Koenig  and  Hildebrand 
go  so  far  as  to  emphasize  the  necessity  to  ascertain  how  the  nerve 


ABDOMEN 


137 


strings  are  dispersed,  by  first  making  a  lateral   incision  into  the 
tumour,  even  after  they  can  state  that  there  is  a  myelomeningocele. 

All  these  procedures,  the 
reason  for  which  no  surgeon 
would  dispute  until  recently, 
may  now  be  rendered  super- 
fluous by  the  Rontgen  method. 
The  skiagraph  shows  not  only 
whether  there  is  an  opening 
in  the  bone,  but  also  tells  of 
the  presence  and  sometimes 
even  of  the  expansion  of  the 
nerve  substance  in  the  sac 
Fig.  85  shows  the  meningo- 
cele of  a  boy  of  two  months. 
In  Fig.  86  the  communicating 
opening  in  the  column  can  be 
recognised. 

In  those  rare  cases  in 
which  the  presence  of  lipoma 
or  fibromyoma  is  in  question, 
it  is  again  the  skiagraph  which 
gives  the  needed  information. 
Fig.  87  represents  a  spec- 
imen of  the  lumbo-sacral  type  of  spina  bifida  in  a  boy  of  five 
weeks.  The  integrity  of  the  spinal  column  and  the  cystic  char- 
acter of  the  contents  of  the  sac  are  apparent. 

Fig.  88  illustrates  the  same  case  in  antero- 
posterior projection. 

In  this  case  gangrene  of  the  surface  of  the 
tumour  induced  the  author  to  resort  to  extir- 
pation, which  verified  the  correctness  of  the 
skiagraph.  Had  there  been  no  gangrene,  he 
would  have,  on  the  testimony  of  the  skiagraph, 
selected  the  injection  treatment. 

Value   in   Gynaecology. — The-  usefulness  of 
the  Rontgen  rays  in  gynaecology  is  still  limited. 
Many  trials  have  been  made  to   obtain  repre- 
sentation of  the  uterus,  but  they  have  always 
^Vtam  Wra™    given  unsatisfactory  results.    In  a  few  instances 


pIG.  yo. — Extrauterine  Mole,  con- 
taining FCETUS,  REMOVED  BY  LAP- 
AROTOMY. 


138 


THE    RONTGEN    RAYS 


the  gravid  uterus  and  the  faint  outlines  of  the  foetus  have  been 
detected. 

Value  in  Obstetrics. — In  obstetrics  the  advantages  are  greater, 
since  so  many  important  questions  hinge  on  the  condition  of  the 


Fig.  92. — Embryo  of  Ten  Weeks. 


Fig.  93.—  Foetus  of  Four  Months.    Abortus  caused  by  Syphilis. 

139 


140 


THE    KONTGEN    EAYS 


pelvis.       Symmetry    and    asymmetry    of    the    pelvis,    ankylosis, 
changes  in  the  iliosacral  joint,  and  the  length  of  the  various  pelvic 


Fig.  94. — Foetus  of  Five  Months. 


ABDOMEN  141 

diameters  can  be  well  shown.  Fig.  89  illustrates  the  elliptical 
shape  of  the  rhachitic  pelvis  in  a  woman  of  twenty-two  years. 

The  deformity  explains  fully  why  she  could  never  be  eon  line.]  in 
a  normal  way.  A  successful  Cesarean  section  has  been  performed 
on  her. 

If  the  exposures  are  made  strictly  under  the  same  conditions, 
the  tube  being  at  the  same  distance  from  the  plate  and  in  the  ox- 
act  perpendicular  direction,  the  measures  of  the  conjugata  vera, 
the  introitus  pelvis,  and  the  transverse  diameters  can  also  be  re- 
lied on. 

After  symphysiotomy  it  can  he  ascertained  whether  any  dias- 
tasis of  the  pubic  bones  has  remained.  In  case  there  is  proof  of 
the  existence  of  considerable  diastasis,  a  second  operation  may 
be  avoided.  The  different  phases  of  development  of  the  foetus 
may  be  studied  by  Figs.  90-94.  (As  to  Osteomalacia,  see  respective 
section,  Chapter  XIII.) 


CHAPTEE    X 
PELVIS  AND  LOWER  EXTREMITY 

Pelvis. — The  technical  difficulties  encountered  in  skiagraphing 
the  abdomen  are  also  observed  in  the  representation  of  the  pelvis. 
The  fact  that  soft  tissues  of  considerable  thickness  must  be  over- 
come explains  why  there  is  diffusion  of  the  rays. 

If  the  pelvis  is  skiagraphed  in  toto,  structural  details  cannot 
be  obtained.  For  the  representation  of  malformations  and  other 
pelvic  abnormalities  a  general  view  is  perfectly  sufficient.  The 
same  can  be  said  of  pelvic  deformities  due  to  congenital  disloca- 
tion of  the  hip  or  to  coxitis  of  old  standing,  the  latter  generally 
being  associated  with  atrophic  changes.  (Compare  Chapter  XIII, 
section  on  Osseous  Atrophy.) 

Examination  of  the  pelvis  is  best  done  in  the  perpendicular 
direction,  the  tube  being  held  as  near  as  possible  and  the  sym- 
physis ordinarily  being  regarded  as  the  centre.  A  dorsal  as  well 
as  an  abdominal  exposure  is  necessary  as  a  rule.  In  children  soft 
tubes  must  be  chosen,  the  time  of  exposure  not  being  longer  than 
two  minutes.  The  best  position  of  the  body  is  when  the  legs  are 
slightly  inverted,  heavy  sand-bags  supporting  them.  When  the 
patient  is  in  the  abdominal  position  the  dorsum  pedis  must  also  be 
supported  by  a  sand-bag.  Fractures  of  the  pelvis  can  be  recog- 
nised, and  by  the  location  of  displaced  splinters  a  conclusion  can 
be  drawn  as  to  possible  injuries  of  the  intrapelvic  organs.  If 
structural  details  are  wanted,  the  use  of  the  diaphragm  is  indis- 
pensable. If  the  author's  diaphragm  is  used,  its  centre  must  be  4 
inches  below  the  umbilicus.  The  iliac  arteries  show  markedly  in 
case  of  calcareous  degeneration. 

In  exstrophy  of  the  bladder  skiagraphing  may  succeed  in  dem- 
onstrating the  extent  of  the  symphyseal  gap,  and  furthermore  the 
result  of  a  plastic  operation. 

Congenital  Dislocation  of  the  Hip. — In  the  treatment  of  con- 
genital dislocation  of  the  hip  skiagraphic  evidence  will  influence 
142 


PELVIS    AND    LOWER    EXTREMITY  143 

the  plan  of  treatment.  The  position  of  the  femoral  head  and  the 
size  and  shape  of  the  acetabulum  are  well  recognised.  If  the  condi- 
tion of  the  acetabulum  is  unfavourable,  bloodless  reduction  should 
not  be  attempted,  and  a  cutting  operation  must  be  performed. 

The  skiagraph  also  shows  whether  reduction  of  a  dislocated  hip 
has  been  successfully  effected  or  not.    It  is  true  that  after  perfect 


Pig.    95. — Congenital   Dislocation   of   Both  Hips  in  a  Gikl  of  Two   and  a 

Half  Years. 

reduction  the  head  of  the  femur  can  be  felt  between  the  spine  and 
the  symphysis  in  the  majority  of  cases,  and  also  that  the  charac- 
teristic noise  can  be  perceived  while  the  head  is  sliding  over  the 
margin  of  the  acetabulum.  But,  on  the  other  hand,  it  cannot  be 
denied  that  the  noise  is  often  indistinct,  and  that  the  thickness 
of  the  muscles  ofttimes  impairs  our  judgment,  so  that  it  is  the 
skiagraph  that   gives   indisputable   information.      Fig.    95    shows 


144 


THE    RONTGEN    RAYS 


congenital  dislocation  of  both  hips  in  a  girl  of  two  and  a  half  years. 
The  skiagraph  proves  the  moderate  extent  of  the  dislocation,  which 


Fio.  96.— Congenital  Dislocation  of  Left  Hip  in  a  Boy  of  Foun  Years,  the 
Right  Hip  being  Normal. 


justified  conservative  measures — viz.,  bloodless  reduction.  This 
was  done  under  anaesthesia,  and  the  result  after  three  years'  treat- 
ment is  entirely  satisfactory. 

Fig.  96  illustrates  the  case  of  a  boy  of  four  years  who  suffered 
from  congenital  dislocation  of  the  left  hip.  Reduction  was  per- 
formed by  Professor  Lorenz,  of  Vienna,  at  St.  Mark's  Hospital, 
the  skiagraph  promising  a  favourable  course  in  advance.  Recov- 
ery was  perfect. 

Fig.  97  illustrates  unilateral  congenital  dislocation  in  a  girl  of 
seventeen  years.  The  acetabulum  proves  to  be  well  formed.  The 
age  of  the  patient,  of  course,  was  not  in  favour  of  bloodless  reposi- 


PELVIS    AND    LOWEK    EXTKEMITY  145 

lion,  so  that  division  of  the  muscles  and  permanenl  extension  was 
resorted  to.     The  result  is  good. 

Inflammatory  Processes  in  the  Hip. — At  the  early  stage  of  in- 
flammatory processes  in  the  hip-joint  a  correct  diagnosis  is  of  ut- 


Fig.   97. — Congenital   Dislocation   of  Hip  in  a  Girl  of   Seventeen  Years, 
the  Empty  Acetabulum  showing  Well  Formed. 

most  importance.    In  doubtful  cases  the  rays  will  determine  whether 
simple,  traumatic,  or  tuberculous  coxitis  (Fig.  98)  is  present.    In 
11 


146 


THE    KONTGEN    RAYS 


view  of  the  great  difference  in  treatment,  the  immense  importance 
of  a  positive  diagnosis  is  evident.  It  is  always  advisable  to  skia- 
graph both  hips,  so  that  the  healthy  and  diseased  side  can  be  com- 


TUBERCULOUS    HlP-JOINT. 


pared.    After  a  general  view  is  obtained  the  diaphragm  must  be 
used  for  the  better  recognition  of  structural  details. 

In  a  normal  hip-joint  there  is  a  regular  semicircular  light 
area  between  the  femoral  head  and  the  acetabulum,  while  in  a  tu- 
berculous hip  the  articular  outlines,  instead  of  being  regular  and 
marked,  are  irregular  and  diffuse.  In  the  beginning  of  the  proc- 
ess, however,  these  signs  may  be  overlooked.  Slight  projections  of 
the  femoral  head  are  often  found  at  an  early  stage  and  indicate 


PELVIS    AND    LOWER    EXTREMITY  147 

the  presence  of  fungous  granulations.  Later,  cheesy  foci  in  the 
acetabulum,  the  head,  the  neck,  and  the  trochanter  major  can  often 
be  detected.  Such  processes  must  be  differentiated  from  osteo- 
myelitic  foci,  which  have  originated  within  the  bone  and  grad- 
ually entered  the  joint.  After  the  healing  process  is  completed, 
the  degree  of  atrophy  of  the  femur  and  the  extent  of  the  anky- 
losis can  be  well  studied.  Osteomyelitic  foci  and  sequestra  are 
naturally  well  shown.  (Compare  section  on  Osteomyelitis,  Chap- 
ter XIII.) 

Arthritis  Deformans  Coxae  is  characterized  by  the  skiagraphic 
representation  of  osseous  proliferations  from  the  articular  outlines 
of  the  head  of  the  femur,  the  shape  of  which  sometimes  reminds 
one  of  a  papilloma.  (Compare  section  on  Arthritis,  Chapter  XIII.) 

FEMUR 

It  is  acknowledged  that  in  differentiating  between  fracture  of 
the  acetabular  margin  or  of  the  neck  of  the  femur  and  dislocation 
and  contusion  of  the  hip,  grave  errors  were  formerly  committed 
by  the  best  surgical  authorities.  The  Rontgen  rays  have  made 
it  possible  to  avoid  these  embarrassing  errors.  Especially  has 
fracture  of  the  acetabular  margin,  with  its  bad  functional  prog- 
nosis, seldom  been  diagnosed  before  the  advent  of  the  rays,  frac- 
ture of  the  neck  of  the  femur  generally  having  been  assumed.  On 
the  strength  of  skiagraphic  information  the  author  was  able  to 
remove  acetabular  splinters  with  safety,  thus  restoring  functional 
ability  in  two  instances. 

The  rays  also  show  that  a  sharp  line  of  distinction  between 
intracapsular  and  extracapsular  fracture  of  the  neck  of  the  femur 
cannot  be  drawn,  and  that  in  the  so-called  extracapsular  variety 
the  fracture  line  generally  extends  into  the  intracapsular  region, 
and  conversely  that  in  intracapsular  fracture  the  fracture  line 
often  extends  somewhat  outside  the  joint.  The  principles  of 
treatment  must  be  modified  accordingly. 

The  skiagraphic  proof  of  the  presence  of  impaction  implies  the 
omissions  of  many  manipulations,  and  suggests  immediate  im- 
mobilization in  the  impacted  position. 

The  diagnosis  of  isolated  fracture  of  the  trochanter  major 
will  also  no  longer  be  confounded  with  contusion. 

Fig.  99  shows  fracture  of  the  neck  of  the  femur  in  a  girl  of 


148  THE    RONTGEN    RAYS 

fourteen  years.  It  is  interesting  to  note  the  transverse  position  of 
the  fragment,  while  the  normal  femoral  neck  of  the  healthy  side 
shows  a  longitudinal  direction. 

Fracture  of  the  femoral  diaplujsis  can  be  easily  diagnosticated 
as  such  without  the  aid  of  the  Rontgen  rays.    Still,  in  view  of  the 


Pig.  99. — Fracture  of  Femoral  Neck. 

well-known  tendency  of  displacement,  recognition  of  the  exact  re- 
lations of  the  broken  fragments  is  of  great  practical  importance. 
After  reposition  is  accomplished  and  an  immobilizing  dressing 
applied,  it  is  advisable  to  ascertain  by  skiagraphic  examination 
whether  apposition  is  perfect.  One  is  often  surprised  about  this 
aberration,  the  fragments  still  being  displaced  to  one  side  or  an- 
other. Then  there  is  still  enough  time  to  correct  after  the  dress- 
ing is  again  removed.     (See  Chapter  XYI  on  Corrections.) 

The  necessity  of  always  taking  two  skiagraphs  in  different 
projection  planes  is  also  illustrated  hy  Figs.  33  and  31.  The 
frontal  skiagraph,  Fig.  33,  represents  the  fracture  of  a  boy  of  seven 


PELVIS    AND    LOWER    EXTREMITY  149 

years  sustained  seven  weeks  before  being  ekiagraphed.  Ii  -hows 
angular  deformity  only,  which  would  suggesi  no  other  correct- 
ing procedure  than  inward  pressure.  But  Fig.  34,  taken  in  tin- 
dorsal  position,  shows  malunion,  the  fragments  overlapping  each 
other.  A  condition  of  this  kind  would  certainly  not  be  corrected 
by  such  simple  interference. 

The  direction  of  the  fragments  also  suggested  tin.'  direction  of 
the  force  which  had  to  be  alongside  and  parallel  to  them.  Tins 
was  accomplished  by  placing  the  anaesthetized  patient  at  the  edge 
cf  the  table  where  manual  force  sufficed  to  separate  the  fragments, 


i_£i 


1H 

Fig.  100.— Fracture  of  Femur,  followed  by  Necrosis.     (See  Fig.  101.) 


so  that  the  lower  one  could  be  pulled  downward  into  proper  appo- 
sition. Recovery  was  perfect,  no  shortening  being  present.  If 
this  procedure  had  been  unsuccessful,   separation  by  the   chisel 


150 


THE    RONTGEN    RAYS 


**'  "'^\ 


' 


would  have  been  resorted  to.    As  to  the  question  of  translueency  in 
this  case,  see  p.  52. 

Fig.  100  illustrates  the  case  of  a  boy  of  seven  years  who  was 
thrown  from  the  roof  of  a  six-story  house,  the  wash-lines  in  the 
yard  fortunately  diminishing  the  force  of  the  fall.  He  sus- 
tained a  compound  fracture  at  the  upper  third  of  the  femur,  and 
was  discharged  from  the  hospital  four  months  after  the  accident. 

When  the  author  saw  the  patient  for 
the  first  time  there  was  still  disturbance 
of  function,  and  a  fistula  in  the  middle 
of  the  thigh  discharged  a  moderate 
amount  of  pus.  The  skiagraph  revealed 
the  presence  of  four  bone-splinters, 
three  being  exfoliated  from  the  cortex 
and  one  lying  in  its  coffin  in  the  cen- 
tre. Their  removal  under  the  guidance 
of  the  rays  was  a  matter  of  ease,  be- 
cause their  size,  shape  (Fig.  101),  and 
position  could  be  ascertained  before- 
hand. Thus  the  exact  direction  as  well 
as  the  length  of  the  incision  could  also 
be  determined. 

The  large  splinter,  which  is  recog- 
nised as  exfoliating  from  the  outer  as- 
pect of  the  femur,  could  be  felt  on 
introducing  the  probe,  but  nothing 
pointed  to  the  presence  of  the  other 
splinters.  Without  the  Rontgen  method 
the  author  would  probably  have  been 
satisfied  with  the  extraction  of  this 
large  splinter,  and  might  not  have 
thought  of  the  probability  of  the  presence  of  the  other  sequestra 
until  the  continuation  of  the  suppuration  would  have  called  his 
attention  upon  so  deplorable  a  fact.  And  this  might  not  have 
occurred  until  months  afterward,  while  under  the  present  favour- 
able circumstances  recovery  was  perfect  after  six  weeks. 

Femoral  Aneurysm. — In  studying  the  current  literature  on  this 
subject  one  gets  the  impression  that  the  diagnosis  of  femoral  aneu- 
rysm is  very  easy.  It  is  true  that  in  the  majority  of  cases  the  symp- 
toms are  well  marked,  and  the  diagnosis  can  be  made  on  simple 


Fig.  101.  —  Sequestra  indi- 
cated by  Skiagraph  Fig. 
100,  after  removal. 


PELVIS    AND    LOWER    EXTREMITY  151 

inspection.  But  in  some  instances,  as  the  following  case  will  show, 
the  greatest  diagnostic  difficulties  may  be  offered. 

The  patient,  a  healthy  man  of  sixty-nine  years,  was  struck 
heavily  by  an  iron  bar  at  the  lower  third  of  his  left  thigh  three 
years  before  being  examined  first  by  the  author.  He  was  laid  up 
for  several  weeks,  constant  pain  being  present  in  this  region. 
Later  the  pain  was  supposed  to  be  rheumatic,  until  the  patient 
noticed  a  tumour  of  the  size  of  a  lemon  in  the  same  area,  which 
gradually  increased,  the  pain  sometimes  being  intense.  The  sur- 
face of  the  tumour  becoming  red  and  tender,  slight  fluctuation 
also  being  assumed  at  several  places,  the  development  of  an  abscess 
was  thought  of.  Immobilization  and  fomentations  reduced  the 
inflammatory  signs  and  the  swelling  decreased  somewhat. 

When  the  author  saw  the  patient  for  the  first  time  he  found  a 
very  large,  well-defined  ovoid  tumour  of  extreme  hardness,  a 
small  area  of  it  only  appearing  elastic.  There  was  not  the  slight- 
est sign  of  pulsation  within  the  extent  of  the  tumour,  which 
reached  from  the  internal  femoral  condyle  up  to  the  groin.  Xoth- 
ing  abnormal  could  be  detected  at  the  lower  leg  or  foot. 

There  had  been  slight  fever  as  long  as  the  inflammatory  proc- 
ess had  lasted,  but  now  the  temperature  was  normal  and  the  pulse 
84.  Considering  the  seat,  the  slow  growth,  the  immobility,  the 
bone-like  hardness,  and  the  entire  absence  of  pulsation  in  the 
tumour,  the  author  thought  that  the  favourite  neoplasm  of  this 
region  might  be  present — viz.,  the  osteosarcoma,  originating  from 
the  femoral  epiphysis.  This  could  have  meant  disarticulation  of 
the  diseased  extremity.  But  before  resolving  on  such  a  grave 
suggestion  the  author  determined  to  consult  the  Eontgen  rays. 
The  skiagraph  revealed  the  absolute  integrity  of  the  femur,  thus 
excluding  the  possibility  of  osteosarcoma.  Exploratory  aspira- 
tions yielded  blood,  the  microscopical  examination  of  which 
showed  nothing  extraordinary.  Echinococcus  appeared  to  be  im- 
probable, in  view  of  its  extremely  rare  occurrence  in  this  country. 
Osteomyelitis  could  be  excluded  definitely  on  the  basis  of  the  his- 
tory. In  osteomyelitis,  because  of  its  transparency,  a  focus  would 
also  have  shown  itself  on  the  skiagraphic  plate,  and  the  same 
would  be  true  in  the  case  of  necrosis. 

There  was,  however,  the  possibility  of  a  sarcoma  of  the  sheath 
of  the  femoral  artery,  or  of  a  fibroma,  originating  from  the  inter- 
muscular tissue  and  fascia,  or  of  an  angiolipoma. 


152 


THE    KONTGEN    RAYS 


In  view  of  these  diagnostic  uncertainties,  the  author  thought 
it  best  to  resort  to  an  exploratory  incision  in  order  to  exsect  a 
portion  of  the  tumour  for  microscopical  examination. 

After  making  an  incision  alongside  the  inner  margin  of  the 
sartorius  muscle,  the  fibres  of  the  vastus  internus  muscle  were 
divided  with  great  care.  But  in  spite  of  these  precautions,  a  jet  of 
arterial  blood  sprang  up,  and  now  the  riddle  was  solved.  A  large 
femoral  aneurysm  was  situated  above  the  adductor.  By  forcible 
pressure  the  haemorrhage  was  stopped  until  Esmarch's  bandage 
was  applied,  and  the  author  ligated  the  femoral  artery  in  Scarpa's 


Fig.  102.— Popliteal  Aneurysm,  showing  Phlebolith. 


triangle.   The  large  sac,  which  was  entirely  filled  up  by  fibrin-clots, 
was  now  exsected. 

It  seems  probable  that  the  aneurysm  was  of  traumatic  origin, 


PELVIS    AND    LOWER    EXTREMITY 


153 


dating  from  the  injury  sustained  three  years  ago.  The  arterial 
walls  having  been  squeezed  and  partially  crushed,  the  artery 
became  dilated;  and  from  the  enormous  thickening  of  the  sac  it 
would  seem  that  this 
dilatation  was  followed 
by  abundant  cell-prolif- 
eration in  the  arterial 
walls  and  their  vicinity. 
There  was  also  an  enor- 
mous amount  of  pale 
fibrin  in  tough  layers. 
One  of  the  fibrin  clots 
showed  the  circulatory 
channel,  the  calibre  of 
which  was  much  small- 
er than  that  of  a  nor- 
mal femoral  artery.  All 
these  points  would  ac- 
count for  the  absence  of 
pulsation. 

While  in  this  case 
the  Kontgen  rays  failed 
to  give  any  positive  in- 
formation as  to  the 
character  of  the  tu- 
mour, the  shadow  caused  by  the  aneurysm  being  so  slight  that 
interpretation  would  have  been  hazardous,  they  were  of  great  value 
inasmuch  as  they  excluded  several  possibilities — viz.,  osteoma, 
osteochondroma,  and  osteosarcoma.  (As  to  Osteosarcoma  and 
Syphilis,  see  Chapter  XIII.) 

Fig.  102  illustrates  a  popliteal  aneurysm  in  a  man  of  fifty  years 
who  had  sustained  an  injury  of  the  popliteal  space  three  years 
before  being  skiagraphed.  The  outlines  of  the  large  sac  are  not 
very  marked,  but  could  still  be  recognised.  Most  of  the  details 
are  lost  in  the  reproduction.  At  the  inner  margin  a  phlebolith 
is  shown.  The  tumour  did  not  pulsate  at  all.  It  was  only  on 
auscultation  that  a  bruit  was  observed.  The  thickness  of  the 
sac  (Fig.  103),  as  shown  after  extirpation,  explains  this  rare  phe- 
nomenon. 


Pig.    103.- 


-Popliteal     Aneukysm   (Compare  Skia- 
graph Fig.  96). 


154 


THE    KONTGEN    EAYS 


KNEE-JOINT 

A  good  skiagraph  of  the  knee-joint  (Fig.  104)  illustrates  its 
anatomical  relations  better  than  any  of  the  illustrations  in  the  text- 
books on  anatomy,  no  matter  how  beautiful  they  may  appear. 
Being  the  frequent  seat  of  simple  as  well  as  of  traumatic  and 
tuberculous  inflammations,  it  offers  many  opportunities  for  skia- 
graphy differentiation.  Eecognition  of  the  various  injuries  of 
the  knee-joint  has  become  much  easier,  since  we  are  able  to  show 


Fig.  104.— Normal  Knee-joint. 


even  a  displacement  of  one  of  the  menisci  tibiae.  Floating  bodies 
in  the  knees  can  be  located  and  calcification  of  the  popliteal  artery 
is  easily  recognised. 


PELVIS    AND    LOWER    EXTREMITY  155 

Patella. — While  the  diagnosis  of  a  fracture  of  the  patella  by  the 
ordinary  method  is  easy,  as  a  rule,  there  are  instances  reported  in 
which  contusion  or  impaction  has  been  assumed.     But  the  skia- 


Pig.  105. — Patellar  Fragments  turned  after  Wiring. 

graph  has  revealed  the  presence  of  multiple  fractures.  It  is  true, 
that  if  the  injury  is  examined  just  after  the  fracture  occurred, 
crepitus  is  generally  produced,  but  afterward  the  intervention  of 
blood-clots  between  the  fragments  prevents  its  production. 

If  the  periosteal  coat  of  the  patella  remained  intact  there  is  no 
displacement,  and  consequently  no  crepitus.  The  same  rule  ap- 
plies to  fracture  of  a  small  portion  of  the  patella. 

It  is  evident  that  in  case  of  extreme  extravasation,  when,  for 
instance,  the  prepatellar  bursse  are  distended  by  coagula,  palpa- 
tion of  the  fragments  becomes  so  difficult  that  the  injury  may  be 
taken  for  contusion  of  the  knee-joint. 


156 


THE    KONTGEN    EAYS 


With  few  exceptions  union  in  transverse  fracture  of  the  pa- 
tella, if  not  sutured,  fails  to  become  osseous,  fibrous  bands  filling 
up  the  gap  between  the  fragments.    In  such  an  event  the  function 


Fig. 


106. — Diastasis    op   Patellar    Fragments    Twenty   Years    after    the 

Injury. 


of  the  joint  is  impaired — inability  to  perform  extension  and 
thorough  flexion,  considerable  atrophy  of  the  muscles  and  greater 
or  lesser  degree  of  knock-knee  being  the  predominating  symptoms. 
While  those  patients  who  follow  a  light  occupation  may  not  be 
incapacitated  and  can  carry  their  burden  with  the  aid  of  a  knee- 
cap, working  men  are  deprived  of  their  means  of  making  a  living 
by  not  possessing  the  use  of  their  limb.  This  shows  how  impor- 
tant it  is,  when  the  question  of  an  operation  turns  up,  to  have  an 
exact  anatomic  representation  of  the  area  involved — in  other 
words,  a  good  skiagraph. 


PELVIS    AND    LOWER    EXTREMITY 


157 


Whether  an  indentated  plaster-of-Paris  dressing  will  in  cases 
of  little  or  no  diastasis  suffice  to  bold  the  fragments  together, 
will  best  be  determined  on  the  basis  of  a  skiagraph.  And,  fur- 
thermore, whether  this  mode  of  immobilization  was  successful  in 
keeping  the  fragments  in  apposition  will  be  ascertained  by  skia- 
graphy examination  mode  through  the  plaster-of-Paris  dressing 
thereafter.  This  indentated  dressing  consists  in  applying  the 
plaster  bandages  around  the  surgeon's  fingers,  while  the  displaced 
fragment  is  tightly  grasped  and   pushed    down    by   an   assistant. 


Pig.  107. — Transverse  Fracture  of  the  Patella. 


Thus  a  wall  is  formed  around  the  digital  impressions,  which,  after 
becoming  dry,  holds  the  reduced  fragments  in  place. 

Whenever  apposition  by  this  bloodless  method  is  tried  in  vain, 
wiring  should  be  performed.     This  is  done  by  introducing  a  long 


158 


THE    BONTGEN    EAYS 


Fig.    108. — Normal    Sesamoid     of 
the  Semitendinosus  Muscle. 


and  strong  needle  armed  with  silver  wire  into  the  quadriceps  ten- 
don just  above  the  patellar  margin  and  through  the  patellar  liga- 
ment on  the  lower  margin  of  the  lower  fragment;,  the  wire  being 

twisted  above  the  middle  of  the 
fracture  line  and  its  ends  pro- 
truding through  the  suture  line 
of  the  skin. 

It  could  be  observed  by  the 
author,  thanks  to  the  Bontgen 
method,  at  an  early  stage,  that 
the  fragments  became  separated 
because  muscular  traction  broke 
the  wire.  This  observation  makes 
it  imperative  to  select  very  strong 
wire  for  this  special  purpose.  Fig. 
105  illustrates  a  case  in  which  the 
fragment  turned  outward  because 
the  wire  broke  three  weeks  after 
the  operation. 

Fig.  106  illustrates  the  im- 
mense diastasis  of  the  fragments  in  a  man  of  fifty  years  who  sus- 
tained the  fracture  twenty  years  ago.  His  walking  was  rendered 
uncertain  so  that  he  slipped  repeatedly,  which  resulted  in  a  fract- 
ure of  both  wrists,  the  humerus,  and  several  ribs  at  various  in- 
tervals. 

Fig.  107  shows  a  considerable  gap  caused  by  a  transversa 
fracture  of  the  patella,  in  a  man  of  thirty-two  years.  The  pa- 
tient was  a  letter-carrier  and  when  showed  the  skiagraph  he  real- 
ized fully  that  for  the  thorough  restoration  of  the  function  wiring 
was  necessary,  the  diastasis  being  too  large  to  be  overcome  by  an 
indentated  dressing.  The  results  of  these  operations  are  always 
good,  provided  thorough  aseptic  precautions  are  taken  and  the 
hands  kept  off  the  tissues. 

Regarding  the  popliteal  space,  it  must  be  borne  in  mind  that 
a  well-defined  shadow  sometimes  shows  in  it  which  might  be  taken 
for  a  bone  fragment  or  a  foreign  body,  but  which  in  reality  is  a 
normal  sesamoid  of  the  semitendinous  muscle  (see  Fig.  108).  This 
sesamoid  is  found  in  about  8  per  cent  of  all  persons  examined. 
As  to  phleboliths,  compare  Fig.  102. 
Differentiation  between  bony  and  fibrous  ankylosis  is  now  easy. 


PELVIS    AND    LOWER    EXTREMITY  159 

This  is  most  important,  since  bony  ankylosis  can  be  remedied 
only  by  separation  by  a  chisel,  while  in  fibrous  ankylosis  forcible 
motions  may  be  resorted  to.  Fig.  109  illustrates  a  case  of  osseous 
ankylosis,  which  did  not  seem  to  be  a  favourable  object  for  oper- 
ation. 

In  tuberculosis  of  the  lenee  the  progress  of  healing  can  be 
observed  by  the  rays  after  resection  as  well  as  after  the  injection 
of  iodoform  glycerine.  While  a  norma]  knee-joint  .-bows  marked 
regularity  of  the  outlines  of  the  articular  surfaces,  the  contours 
of  a  tuberculous  knee  appear  irregular  and  diffuse,  and  the  inter- 
articular  gap  is  enlarged.  Later,  when  cheesy  Foci  have  formed, 
their  areas  become  translucent.     The  cartilage  is  sometimes  en- 


Fig.  109. — Osseous  Ankylosis  of  Knee. 

tirely  destroyed  and  produces  no  shadow.     As  to  further  details, 
compare  section  on  Tuberculosis,  Chapter  XIII. 

The  best  skiagraphs  are,  as  a  rule,  obtained  in  the  lateral  posi- 
tion, the  external  condyle  resting  on  the  plate.  The  dorsum  must 
be  well  supported  during  this  procedure.    As  a  rule  an  exposure  of 


160  THE    EONTGEN    RAYS 

two  minutes  is  sufficient  in  an  adult.  To  show  details,  the  use  of 
the  diaphragm  is  necessary,  by  which  the  outlines  of  the  joint,  the 
interarticular  space,  the  eminentige  intercondylicae,  and  the  con- 
dyles are  well  represented.  The  patellar  ligament  and  the  infra- 
patellar and  suprapatellar  bursae  must  also  be  recognised. 

No  attempt  should  be  made  to  remove  a  foreign  body  before 
skiagraphic  evidence  is  furnished.  How  disappointing  it  will 
often  be  if  this  advice  is  disregarded,  is  illustrated  by  the  case 
of  a  man  of  twenty  years  who  was  shot  in  the  middle  of  the  right 
femur.  Suffering  considerable  pain  along  the  thigh,  he  demanded 
the  immediate  removal  of  the  bullet.  It  seems  pardonable  in  this 
case  that  the  family  physician  should  attempt  to  extract  the  bullet 
without  the  aid  of  the  Eontgen  rays.  He  was  punished,  however, 
for  his  adventurous  attempt.  Although  the  soft  tissues  were  ex- 
posed to  a  great  extent,  from  the  middle  of  the  thigh  down  to  the 
knee,  he  could  not  find  the  bullet.  When  a  skiagraph  was  taken 
at  last,  the  bullet  was  located  in  the  knee-joint  near  the  popliteal 
space.  Extraction  could  then  be  performed  in  a  few  minutes,  a 
small  incision  having  proved  to  be  sufficient  for  the  purpose. 
While  there  was  no  reaction  within  the  knee-joint,  the  patient  had 
to  suffer  for  weeks  from  the  large  gaping  wound  of  his  thigh, 
which  was  the  result  of  the  futile  and  prolonged  searching. 

It  is  a  deplorable  fact  that  this  modus  operandi  still  corre- 
sponds to  the  every-day  routine  of  a  number  of  surgeons. 


LEG 


When  we  realize  that  fractures  of  the  leg  constitute  about  16 
per  cent  of  all  fractures,  and  that  they  show  a  great  tendency  to 
displacement,  the  importance  of  the  Eontgen  rays  as  a  controlling 
means  during  treatment  becomes  evident  at  once.  Fig.  110  illus- 
trates an  oblique  fracture  of  the  tibia  in  a  boy  of  ten  years,  show- 
ing slight  axial  displacement  only,  which  suggested  a  small  degree 
of  downward  pressure  on  the  anterior  aspect  of  the  tibia. 

Fig.  Ill  illustrates  the  same  type  of  fracture  in  a  boy  of  eight 
years.  There  is  a  moderate  degree  of  angular  displacement,  and 
the  considerable  gaping  at  the  anterior  side  suggests  forcible  down- 
ward pressure. 

Fig.  112  illustrates  that  type  which  is  called  fracture  a  la  bee 


PELVIS    AND    LOWER    EXTREMITY  161 

de  flute  in  a  boy  of  nine  years.  The  skiagraph  suggested  simple 
immobilization,  since  there  were  no  signs  of  displacement, 

As  to  the  necessity  of  taking  two  skiagraphs  in  different  projec- 
tion plans,  see  Chapter  XVII  on  the  Medico-Legal  Aspects  of  the 
Rontgen  Rays  (Figs.  259,  260). 

The  presence  and  extent  of  osteomyelitis,  so  frequently  found 
in  the  tibia,  can  be  diagnosed  by  the  rays,  the  focus  of  the  dis- 


Fig.  110.— Oblique  Fracture  of  the  Tibia,  showing  Slight 
Axial  Displacement. 

ease  always  appearing  well  marked.  The  ease  and  security  with 
which  operative  procedures  in  these  cases  can  be  carried  out 
under  the  control  of  the  rays  cannot  be  too  strongly  emphasized. 
Just  as  in  osteomyelitis  of  the  femur  and  humerus  it  was  deemed 
advisable  in  former  years  to  chisel  up  the  whole  length  of  the 
12 


162 


THE    RONTGEN    RAYS 


bone  in  order  to  be  sure  that  every  possible  focns  had  really 
been  reached.  Now  the  skiagraph  shows  the  length  of  the  inci- 
sion that  is  necessary  for  a  thorough  removal.     It  is  naturally 

easier  to  represent  the  foci 
in  the  tibia  than  in  the 
femur.  Periosteal  prolif- 
erations are  especially  well 
shown  at  the  tibia. 

In  cases  of  mal-union, 
the  rays  indicate  the  mode 
of  correction,  thus  sim- 
plifying a  hitherto  com- 
plicated procedure.  The 
arrest  of  growth  of  the 
tibia  after  operations  for 
necrosis  can  be  well  stud- 
ied. Rachitis  and  tuber- 
culosis also  offer  a  wide 
field  for  study  in  this  re- 
gion. See  chapter  on 
these  special  diseases 
(Chapter  XIII). 

Osseous  cysts  at  the 
upper  as  well  as  at  the 
lower  end  of  the  tibial  epiphysis  are  not  of  infrequent  occurrence. 
They  are  confounded  sometimes  with  osteosarcoma — a  most  un- 
fortunate accident,  indeed,  since  it  would  usually  mean  unneces- 
sary amputation.  As  will  be  emphasized  in  the  chapter  on  osseous 
cysts,  the  outlines  of  the  bone  in  osteosarcoma  are  more  or  less 
irregular  and  indefinite,  some  areas  even  appearing  entirely  trans- 
lucent; while  in  osseous  cysts  the  cortex  appears  thin  and  narrow, 
but  well  marked  and  regular.  The  fluid  centre  of  the  bone  is  en- 
tirely translucent,  the  light  shadow  showing  the  same  regularity. 
The  adjacent  epiphyses  are  normal. 

The  principles  of  examining  the  leg  by  the  Rontgen  method 
are  essentially  the  same  as  those  observed  in  studying  the  thigh. 
For  textural  details  the  use  of  the  diaphragm  is  recommended. 

The  Ankle- Joint  and  its  vicinity  are  frequently  the  seat  of  in- 
juries and  diseases  of  various  kinds.  The  history  of  the  faulty 
diagnosis  in  this  region  would  fill   many  volumes.     Nowadays, 


Pig.  111. — Fracture  of  Tjbia,  showing  An- 
terior Gaping. 


PELVIS  AND  LOWER  EXTREMITY 


163 


differentiation  between  fracture,  dislocation,  distortion,  contusion, 

and  inflammatory  processes  is  not  only  easy,  bul  the  mode  of  repo- 
sition as  well  as  of  the  after-treatment  is  also  materially  influenced 
by  the  skiagraphic  findings. 

If  in  the  much-dreaded  malleolar  fracture  the  Etbntgeu  rays 
show  the  direction  of  the  fragment  to  be  upward,  downward 
pressure  must  naturally  be  used  by  the  surgeon,  and  vice  versa.  If 
the  direction  of  the  fragment  is  lateral,  sideward  pressure  is  indi- 
cated. After  reposition  is 
accomplished  a  plaster-of- 
Paris  dressing  is  applied 
in  proportion  to  the  ten- 
dency to  displacement. 
(See  Fig.  113.)  As  al- 
luded to  before,  the  screen 
or  skiagraph  indicates, 
then,  whether  reposition 
was  perfect  or  not.  If 
imperfect,  the  dressing- 
must  be  removed  and  the 
position  corrected.  The 
character  of  the  mistake 
made  being  recognised 
now,  proper  reposition 
can  be  expected  with  a 
greater  degree  of  prob- 
ability. But  if  the  sur- 
geon has  failed  again,  he 
must  change  his  dressing 
until  the  Rontgen  guide 
shows  him  that  he  has 
succeeded  in  his  efforts 
at  reduction. 

The  text-books  gener- 
ally speak  of  one  kind 
of     displacement     only. 

That  such  information  is  insufficient  is  proved  by  the  Rontgen 
rays.  Fig.  114,  for  instance,  represents  a  Pott's  fracture  in  a 
woman  of  thirty-five  years.  The  fact  that  the  internal  as  well 
as  the  external  malleolus  was  fractured  had  been  ascertained  be- 


Fig.    112. — Fracture  a  la  Bec  de  Flvte  of 
the  Tibia  in  a  Boy  of  Nine  Years. 


164 


THE   RONTGEN   RAYS 


fore  the  Rontgen  rays  gave  detailed  information.,  since  ecchymosis, 
intense  pain,  crepitus,  and  abnormal  lateral  mobility  at  the  ankle 
were  present. 

The  author  was  taught  that  reduction  is  best  accomplished  in 
such  cases  by  pushing  the  calcaneum  inward  and  forward.  He  has 
been  surprised  that  in  spite  of  carefully  controlling  the  after- 
treatment,  which  consisted  in  the  appli- 
cation of  a  Dupuytren's  splint,  an  unsat- 
isfactory result  was  obtained  in  most  of 
his  cases.  Finding  undue  prominences 
around  or  below  the  malleoli,  he  consoled 
himself  that  there  was  excessive  callus 
formation. 

The  Rontgen  rays  have  shown  the  fal- 
lacy of  such  theories.  What  we  so  readily 
used  to  term  callous  proliferation  was 
nothing  else  but  a  projecting  piece  of 
bone-fragment,  adherent  in  a  displaced 
position. 

Skiagraph  114  shows  that  while  the 
fibular  fragment  is  laterally  displaced,  the 
tibial  is  directed  downward.  Naturally, 
inward  pressure  upon  the  fibular  frag- 
ment must  put  it  into  perfect  apposi- 
tion. But  the  tibial  fragment  could  not 
be  reduced  laterally  because  it  would  meet 
an  obstacle  in  the  astragalus,  to  which 
it  descended.  But  even  if  there  was 
really  no  obstacle,  the  fragment  could  not 
be  pushed  into  its  normal  position  by 
being  pressed  inwardly  because  of  its 
descension.  The  skiagraph,  by  showing 
us  the  downward  displacement  of  the  fragment,  tells  us  dis- 
tinctly that  proper  reduction  can  be  accomplished  by  ascension 
only — in  other  words,  by  pressure  in  the  upward  direction.  It  is 
only  thus  that  the  widening  of  the  mortise  is  prevented  and  the 
normal  arch  restored. 

The  immobilizing  dressing  must  be  applied  after  the  same 
principles.  In  this  case  the  foot  was  immobilized  after  being 
turned  inward  in  club-foot  shape,  because  this  position  permitted 


PrG.     113. — Dressing    in 
Pott's     Fkacture,     as 

INDICATED         BY        SkIA- 

gbaphic  Anatomy. 


PELVIS    AND    LOWER    EXTREMITY  165 

of  ascension — in  other  words,  of  the  thorough   adaption  of  the 
internal  fragment  to  the  tibia,  as  the  rays  proved. 


Fig.  114. — Pott's  Fracture. 


166 


THE    RONTGEN    RAYS 


No  dressing  accomplishes  the  purpose  of  retaining  the  frag- 
ments better  than  plaster  of  Paris,  since  it  adapts  itself  to  the 
contours  of  the  limb  in  any  desired  shape  or  direction.  The  plas- 
ter-of -Paris  dressing 
may  be  applied  at 
once,  provided  there 
is  thorough  reposi- 
tion. 

From  this  experi- 
ence we  learn  that  the 
proper  treatment  of 
this  type,  just  like 
man}r  other  fractures, 
is  based  upon  individ- 
ualization. And  this 
can  very  seldom  be 
carried  out  without 
resorting  to  applica- 
tion of  the  Rontgen 
rays. 

In  the  case  of  a 
boy  of  twelve  years, 
illustrated  by  Fig. 
115,  it  was  the  tibial 
fragment  only  which 
was  displaced.  Repo- 
sition was  accom- 
plished after  the  prin- 
Fig.  115..— Fracture  of  the  Internal  Malleo-  ciples  emphasized  in 
lus  Reduced.  the    case    just    de- 

scribed. There  was 
considerable  descension,  which,  as  the  skiagraph,  taken  two  weeks 
after  reduction,  shows,  was  well  corrected. 

How  important  it  is  to  take  at  least  two  skiagraphs  in  two 
different  projection  planes  is  illustrated  by  Figs.  116  and  117, 
which  represent  a  Pott's  fracture  associated  with  enormous  dis- 
placement in  a  man  of  forty  years.  Fig.  116  shows  the  fractured 
internal  malleolus  very  distinctly,  while  the  fibular  fragment  is 
veiled.  At  the  same  time  backward  displacement  of  the  foot  ap- 
pears well  marked.     During  the  exposure  the  external  surface  of 


PELVIS    AND    LOWKK    EXTREMITY 


167 


the  foot  rested  on  the  plate.  Fig.  117  taken  in  slightly  oblique 
antero-posterior  direction,  the  posterior  aspect  of  the  leg  resting 
on  the  plate,  does  not  indicate  the  enormous  backward  displace- 
ment of  the  foot,  but  shows  both  fragments  markedly,  in  other 
words,  the  deficiency  of  Fig.  116  consists  in  not  showing  the  exter- 


Fig.   116.— Fracture  of   Both   Malleoli,   associated   with   Backward  Dis- 
placement of  Foot.     (Compare  Fig.  117.) 


168 


THE    EONTGEN    EAYS 


nal  malleolus  well  enough,  while  Fig.  117  fails  to  indicate 
the  backward  displacement  of  the  foot.  On  the  other  hand,  each 
skiagraph  shows  one  part  of  the  injury  better  than  the  other, 
thereby  supplementing  each  other. 

In  former  years  the  author  would  not  have  thought  that  he 
could  succeed  under  such  aggravating  circumstances  in  getting 


Fig.  117. — Case  illustrated  by  Fig.  116,  in  Oblique  Anteroposterior  Pro- 
jection. 

a  good  functional  result,  while  with  the  Eontgen  guide  reposition 
was  not  only  accomplished  without  the  use  of  an  anaesthetic,  but  the 
functional  result  was  also  blameless.  As  is  evident  from  the  obser- 
vation of  the  cases  described,  the  ankle-joint  must  always  be  ex- 
amined in  different  positions.     To  obtain  a  good  antero-posterior 


PELVIS    AND    LOWEE    EXTREMITY  169 

view  the  use  of  the  diaphragm  is  necessary  (see  Fig.  25).  This 
is  best  accomplished  while  the  patient  assumes  the  recumbent  posi- 
tion. Or  a  board,  like  the  well-known  Vol'kmann's  resection  splint, 
may  support  the  planta  pedis  in  this  position.  Willi  a  gauze  band- 
age the  foot  is  fastened  to  this  plantar  support.  Sometimes  an  Es- 
march  bandage  is  preferable  for  thorough  immobilization  during 
the  exposure.  Sand-hags  niiisl  be  placed  then  around  the  ankle- 
joint  as  well  as  the  knee.  The  time  of  exposure  should  be  two  to 
two  and  a  half  minutes.  In  the  lateral  position  a  good  skiagraph 
can  be  obtained  without  such  preliminaries,  but' it  must  be  consid- 
ered that  a  representation  in  this  position  is  far  less  important 
than  that  in  antero-posterior  projection,  as  far  as  the  proper  an- 
alysis of  the  ankle-joint  is  concerned.  The  time  of  exposure  in  the 
lateral  position  may  be  somewhat  less  than  two  minutes. 

The  healing  process,  after  operation  for  pes  equinovarus  and 
valgus,  can  be  easily  studied  and  influenced  accordingly.  Most 
cases  of  so-called  distortion  prove  to  be  fractures  pure  and  simple 
when  looked  at  by  means  of  the  "  Eontgen  eye-glass."  Sometimes 
very  small  splinters  are  represented  which  are  severed  from  the 
bone  surface.  They  are  embedded  in  bloody  effusion,  which  pre- 
vents their  recognition  by  palpation,  so  that  naturally  a  diagnosis 
of  "  sprain  "  is  made.  Massage  can  seldom  be  borne  by  the  pa- 
tient, because  the  friction  caused  by  this  treatment  presses  the 
sharp  splinters  forcibly  against  the  injured  hone.  The  patient 
will,  on  the  other  hand,  be  coriifortable  if  treated  after  the  general 
principles  of  fracture  treatment — i.  e.,  immobilization. 

If  there  are  no  little  bone  fragments,  but  only  hsematoma  from 
lacerated  tissue,  massage  is  the  treatment  par  excellence,  of  course, 
and  immobilization  means  unnecessary  delay. 


FOOT 

Astragalus  and  Calcaneum. — Fractures  of  the  astragalus  and 
calcaneum  were  often  confounded  with  Pott's  fracture,  the  final 
surgical  result  naturally  being  very  unsatisfactory.  Minute  ana- 
tomical knowledge  is  necessary  to  appreciate  a  skiagraph  of  these 
bones  thoroughly.  Fig.  118  shows  fracture  of  the  calcaneum, 
causing  slight  downward  displacement,  in  a  man  of  thirty-eight 
years,  two  months  after  the  injury. 


170  THE    RONTGEJST    KAYS 

How  misleading  the  lack  of  such  knowledge  may  become  is 
evident  from  the  fact  that  the  os  intermedium  cruris  (os  trigonum 
tarsi)  has  been  mistaken  for  a  fragment  severed  from  the  astraga- 


Pio.  118.— Fracture  of  the  Calcaneum. 

lus.  This  bone  is  a  typical  part  of  the  tarsus  of  all  mammalia, 
and  its  frequency  is  estimated  at  from  7  to  8  per  cent.  Shep- 
herd, who  mistook  this  bone  for  a  fractured  fragment,  says: 
"  The  fact  that  this  fracture  is  not  mentioned  in  any  of  the 
text-books  on  surgery  or  in  special  treatises  on  fractures  would 
easily  be  accounted  for  by  its  only  being  discovered  by  dissection; 
it  causes  no  deformity,  and  the  s3rmptoms  it  would  cause  during 
life  would  probably  be  obscure."  The  same  author  tried  to  pro- 
duce this  fracture  artificially  on  the  cadaver,  but  "  in  every  case," 
he  says,  "  where  this  manoeuvre  was  performed,  I  failed,  even 
when  the  greatest  force  was  used,  to  break  off  a  little  process  of  the 
bone  mentioned  above."  Pfitzner  regards  the  os  trigonum  tarsi  as 
an  integral  part  of  the  posterior  process  of  the  astragalus  in  the 
adult,  which  is  analogous  to  the  os  intermedium  antibrachii.  Fig. 
119  shows  a  normal  os  intermedium  cruris  at  the  posterior  aspect 
of  the  astragalus.  This  condition  was  detected  accidentally  when 
the  patient  was  skiagraphed  after  his  foot  was  crushed  by  an  ele- 
vator.   The  ossa  cuneiformia  were  shattered. 


PELVIS    AND    LOWER    EXTREMITY  171 

The  examination  of  the  tarsal  bones  is  besi  done  in  the  Lateral 
position.  A  skiagraph,  taken  in  this  position,  shows  the  ankle- 
joint  as  a  well-marked  Line.  The  interstices  between  the  astraga- 
lus and  the  calcaneum,  between  the  cuboid  and  the  calcaneum,  the 
cuboid  and  the  metatarsal  bones,  the  scaphoid  and  the  cuneiform, 
and  the  astragalus  and  the  scaphoid  must  also  appear  distinct! v. 
The  tendo  Achillis  is  well  recognised.  Arteriosclerosis  of  the 
arteria  tibialis  postica  and  antica  show  well  in  tins  position.  The 
use  of  the  diaphragm  is  recommended  only  for  the  representation 


Fig.  119. — Foot  showing  Os  Thigonum  Taksi. 

of  osseous  foci  or  articular  affections  in  this  region,  although  the 
structural  details  are  generally  fairly  well  shown  without  it.  The 
time  of  exposure  varies  between  one  and  two  minutes,  the  vacuum 
of  the  tube  to  be  taken  low. 


172  THE    RONTGEN    RAYS 

The  isolated  fracture  of  the  other  tarsal  bones  was  seldom  rec- 
ognised in  a  living  person  prior  to  the  discovery  of  the  Rontgen 
rays.  While  the  foot  is  easily  skiagraphed  in  the  direction  of  the 
dorsum  towards  the  planta  pedis  from  the  toes  up  to  the  upper 
third  of  the  metatarsus,  the  first  and  third  cuneiform  bones  and 
the  scaphoid  offer  an  obstacle,  so  that  it  is  necessary  to  skiagraph 
these  portions  transversely  by  having  the  outer  surface  rest  on  the 
plate.  It  is  by  this  procedure  only  that  the  isolated  shadows  of 
the  astragalus,  the  calcaneum,  the  os  cuboicleum,  the  scaphoid, 
and  the  fourth  and  fifth  metatarsal  bones  can  be  distinctly  out- 
lined, so  that  false  interpretations  can  be  excluded  (see  Fig.  24). 

In  children  short  exposures  should  be  striven  at,  the  difficul- 
ties of  keeping  them  quiet  being  great.  Fig.  173  illustrates  a  case 
of  synostosis  of  the  first  and  second  metatarsus  in  a  child  of  two 
weeks.  Although  the  exposure  lasted  a  few  seconds  only,  a  dis- 
tinct reproduction  was  obtained,  the  foot  being  firmly  pressed 
down  on  a  table  by  the  fingers  of  an  assistant  while  the  planta 
pedis  rested  on  the  plate. 

A  good  skiagraph  taken  in  antero-posterior  projection  must 
show  the  outlines  of  Lisfranc's  as  well  as  Chopart's  joint — that  is, 
the  metatarsal  bones  must  show  individually  separated. 

METATARSUS 

As  indicated  above,  the  metatarsus  is  represented  best  while  the 
patient  is  seated  on  a  chair,  the  planta  pedis  resting  on  the  plate. 

Our  knowledge  on  the  pathology  of  the  much-neglected  meta- 
tarsus became  greatly  widened  by  the  Rontgen  method.  Espe- 
cially the  true  appreciation  of  its  injuries  is  entirely  due  to  the 
rays.    And  injuries  of  the  metatarsus  are  of  extreme  frequency. 

As  to  fractures,  it  may  be  said  that  it  is  generally  accepted 
that  their  superficial  location  makes  their  recognition  easy.  Still, 
while  this  may  be  true  of  the  first  and  fifth  metatarsal  bones,  on 
account  of  their  accessibility,  the  dense  tendinous  and  ligamentous 
tissues  overlying  the  second,  third,  and  fourth  metatarsi  are  apt 
to  veil  the  fracture  signs  within  their  tract.  The  difficulty  of  dif- 
ferentiation is  much  greater  when,  as  is  the  rule,  the  fracture  is 
associated  with  injuries  of  the  soft  tissues,  causing  cedema  and 
swelling. 

How  often  metatarsal  fracture  has  been  overlooked  can  be 


PELVIS    AND    LOWER    EXTREMITY  173 

estimated  by  the  fact  that,  before  the  discovery  of  the  Rontgen 
rays,  most  cases  of  fracture  of  the  second  or  third  metatarsal 
bones  were  mistaken  for  pathological  change  in  the  soft  tissue — in 
the  German  army  known  as  "foot  oedema."  It  was  reserved  for 
the  Rontgen  rays  to  disclose  the  fact  that  this  much-dreaded  con- 
dition was  a  fracture  pure  and  simple,  and  that  it  was  produced 
by  overburdening  the  marching  soldier  (Stechow). 

Text-books  give  but  little  treatment  for  metatarsal  fracture, 
most  of  them  saying  that  it  requires  neither  detailed  description 
nor  any  special  mode  of  treatment.  A  few  maintain  that  if  there 
is  any  displacement  it  will  be  towards  the  dorsum  of  the  foot. 
Only  Hoffa  alludes  to  the  possibility  of  plantar  displacement  also. 
But  nowhere  is  reference  made  to  the  lateral  displacement,  which 
we  regard  as  of  not  infrequent  occurrence,  and  also  as  an  impor- 
tant complication,  since  it  is  always  followed  by  considerable  func- 
tional disturbance.  The  fact  that  the  lateral  displacement  was 
never  before  recognised  explains  fully  why  efforts  of  reduction 
have  been  neither  made  nor  advised;  consequently  the  fragments 
left  to  themselves,  whether  in  a  general  immobilizing  dressing  or 
not,  unite  in  a  deformed  position,  and  bony  enlargements,  as  well 
as  functional  disturbances  are  the  result.  The  cedeinatous  feet 
of  persons  who  must  work  hard,  or  march  or  stand  on  their 
feet  during  the  whole  day,  furnish  a  striking  illustration  of  the 
consequences  of  badly  united  metatarsal  fractures,  as  they  are 
disclosed  at  the  present  time  by  the  Rontgen  rays.  It  is  obvious 
that  the  more  accurate  and  varied  the  diagnoses  are  which  these 
rays  enable  us  to  make,  the  greater  difference  there  must  be  in  our 
plans  of  treatment.  The  experiments  of  the  writer  have  shown 
that  metacarpal  fragments  are  held  in  place  by  elastic  pressure 
(see  section  on  Metacarpus).  The  same  principles  obviously  apply 
to  metatarsal  fracture. 

For  the  fracture  of  a  displaced  metatarsal  bone,  two  rubber 
drainage-tubes  of  moderate  size  are  chosen  and  lightly  pressed  into 
the  adjoining  interosseous  spaces  at  the  dorsum  so  that  they  fill 
them  to  a  certain  extent.  If  two  metatarsi  are  fractured,  three 
drainage-tubes  are  necessary,  and  so  on.  The  tubes  are  kept  in 
situ  by  strips  of  adhesive  plaster;  thus  the  recurrence  of  the  dis- 
placement is  absolutely  prevented.  The  dorsum  is  then  sur- 
rounded by  a  moss-splint,  a  material  that  after  being  dipped  in 
cold  water  adapts  itself  to  the  contours  of  the  foot  like  a  cast. 


174 


THE    EONTGEN    RAYS 


The    whole    is    protected    by    a    plaster-of-Paris    dressing    which 
reaches  from  the  toes  to  the  lower  third  of  the  leg.     The  patient 

remains  in  bed  for 
"  about  ten  clays.  Then 
an  ambulatory  dress- 
ing is  applied  after 
the  principles  eluci- 
dated above. 

When  skiagraphed 
through  the  plaster- 
of-Paris  dressing  the 
formerly  displaced 
fragments  should  be 
found  in  exact  appo- 
sition. If  not,  the 
dressing  must  be  re- 
applied in  the  correct 
position.  There  is  no 
doubt  that  in  pur- 
suing these  therapeu- 
tic principles,  which 
are  based  on  a  correct 
anatomic  diagnosis,  al- 
1  e  g  e  cl  metatarsalgia 
and  similar  ailments 
will  become  very  rare 
affections. 

Many  cases  of  so- 
called  neuralgia,  neu- 
ritis, rheumatism,  os- 
teomyelitis, suspected 
tuberculosis,  etc.,  belong  to  the  same  category.  The  small  bony 
enlargements  of  the  foot,  its  broadening,  and  sometimes  the  callo- 
sities following  metatarsal  fracture,  were  observed  in  former  years; 
but  they  were  misinterpreted  in  the  majority  of  cases,  since  they 
were  due  to  the  badly  united  fracture  only.  Union  in  a  displaced 
position,  especially  in  lateral  displacement,  must  necessarily  lead 
to  compression  of  the  digital  nerves.  It  is  evident  that  treatment 
of  such  cases  of  "  peripheral  neuritis  "  can  consist  only  in  reducing 
the  fragments  to  their  proper  position  by  osteotomy. 


J 

Fig.  120. — Fracture  of  Second  and  Third  Met- 
atarsus, FOLLOWED  BY  LATERAL  DISPLACE- 
MENT. 


PELVIS    AM)    LOWER    EXTREMITY 


17.". 


Pain  induced  by  walking  points  to  dorsal  or  plantar  displace- 
ment, while  metatarsalgia,  coming  on  in  a  paroxysmal  manner, 
is  generally  due  to  lateral  displacement.  Metatarsalgia  is  some- 
what analogous  to  coecycodynia,  which,  as  the  author  proved  (see 
Appendix  to  his  Text-Book  on  Fractures,  p.  288)  was  produced 
by  fracture  in  most  cases,  the  fragments  also  having  united  in  a 
deformed  position. 

Fig.  120  illustrates  the  case  of  a  man  of  thirty-one  years  who 
sustained  a  fracture  of  the  lower  epiphyseal  ends  of  the  third 
and    fourth,    and    a    fissure    of    the    second  metatarsus.      While 


Fig.  121. — Fracture  of  Second  Metatarsal  Bone. 


smoothing  the  asphalt  pavement  on  the  street,  holding  an  iron  bar 
of  40  pounds  in  his  hands,  he  was  knocked  down  by  a  street  engine 
which  came  from  behind,  so  that  he  fell  forward.  While  the  sec- 
ond metatarsus  shows  only  a  slight  sideward  bending,  the  dentated 


176  THE    RONTGEN    RAYS 

fragment  of  the  third  metatarsus  is  markedly  displaced  outwardly. 
The  lower  fragment  of  the  fourth  metatarsus  is  not  only  displaced, 
but  its  external  portion  is  also  tightly  pressed  against  the  fifth 
metatarso-phalangeal  joint.  The  patient  was  able  to  walk  in  one 
week  in  an  ambulatory  dressing,  and  made  an  uneventful  recovery. 

Fig.  121  shows  the  fracture  of  the  second  metacarpal  bone  in  a 
man  of  thirty-six  years.  The  displacement  was  mainly  directed 
upward.  Downward  pressure  sufficed  for  reposition,  still  there 
was  slight  lateral  deviation,  which  was  overcome  by  the  interven- 
tion of  a  small  rubber  drainage-tube. 

Fig.  122  is  a  striking  illustration  of  an  injury  of  this  kind.  The 
patient,  a  boy  of  fourteen  years,  sustained  an  injury  of  his  foot 
three  years  before  the  skiagraph  was  taken.  The  swelling  follow- 
ing the  injury  was  thought  to  be  clue  to  contusion,  and  the  foot 
was  consequently  treated  by  the  application  of  fomentations.  The 
thickening  of  the  injured  area,  which  remained,  was  supposed  to 
be  caused  by  an  inflammatory  process,  massage  as  a  local  and  iodide 
as  a  constitutional  therapeutic  agent  being  administered.  The 
possibility  of  a  fracture,  as  shown  by  the  skiagraph,  was  not 
thought  of. 

The  sesamoid  (compare  Fig.  121)  below  the  head  of  the  first 
metatarsal  bone  is  sometimes  fractured  by  direct  violence,  a  fact 
that  was  also  never  before  recognised. 

The  various  osseous  changes  of  the  foot  in  acromegaly  (see 
Fig.  232)  are  an  interesting  subject  for  skiagraphic  study.  The 
phalanges  appear  broader  and  thicker  than  normal  and  show  no 
osteophytes.     The  metatarsi  also  show  massive  structures. 

The  pathological  anatomy  of  hallux  valgus  and  that  of 
arthritis  of  the  large  toe  are  also  much  better  appreciated  and 
judged  since  the  advent  of  the  rays.  Skiagraphs  of  the  toes  are 
frequently  serviceable  in  the  detection  of  foreign  bodies,  espe- 
cially of  needles  and  headless  tacks.  Malformations,  like  syndac- 
tylism (Fig.  172),  etc.,  can  also  be  well  studied.  The  exact  ana- 
tomical diagnosis  that  we  are  now  able  to  make  enables  us  to 
determine  whether  surgical  interference  is  possible,  and  if  so,  it 
outlines  the  modus  operandi. 

To  avoid  false  interpretations  of  skiagraphs  of  children,  it 
should  be  remembered  that  the  lower  epiphyses  of  the  tibia  and 
the  fibula  show  their  osseous  nuclei  in  the  first  and  second  years, 
and  unite  with  the  diaphysis  between  the  eighteenth  and  the 
twenty-fifth  year,  or,  according  to  skiagraphic  evidence,  sometimes 


PELVTS  AND  LOWER  EXTREMITY 


177 


even  before  the  eighteenth  year.  The  osseous  nuclei  of  the  astraga- 
lus and  of  the  calcaneum  appear  intra-utero,  that  of  the  cuboid 
shortly  before  or  after  birth,  that  of  the  cuneiform  between  the 
first  and  fifth  year,  and  that  of  the  scaphoid  from  the  first  to  the 
fifth  year.    The  osseous  nuclei  of  the  metatarsal  bones  and  of  the 


Pig.  122. — Malunion  of  Fracture  of  Large  Toe,  Three  Years  after  the 
Injury,  Causing  Considerable  Pressure. 

phalanges  appear  from  the  second  to  the  ninth  year,  and  unite  with 
the  diaphysis  between  the  sixteenth  and  the  twenty-second  year. 

Injuries  and  diseases  of  the  phalanges  are,  of  course,  easily 
recognised.  For  a  general  view  the  tubal  focus  should  be  directly 
above  the  first  phalanx  of  the  middle  toe.  For  differentiation 
from  arthritis  and  chronic  inflammatory  processes  skiagraphy  is 
most  important.  The  time  of  exposure  should  not  exceed  half  a 
minute — even  in  a  few  seconds  useful  reproductions  of  the  toes 
can  be  obtained  under  favourable  circumstances. 


CHAPTEK    XI 
SHOULDER  AND   UPPER  EXTREMITY 

Shoulder. — The  shoulder  is  fluoroscoped  best  while  the  patient 
is  seated  on  a  chair.  (Compare  section  on  the  Position  of  the 
Patient,  page  59.)  Skiagraphy  may  be  clone  in  the  sitting,  re- 
cumbent, and  abdominal  position.  A  table  is  less  convenient  for 
skiagraphing  of  the  shoulder  than  the  carpeted  floor,  because  the 
outstretched  arm  occupies  much  more  space  than  a  table  can  give, 
and  special  attachments  are  cumbersome. 

The  respiratory  motions  interfere  to  a  certain  extent  with  a 
faultless  reproduction.  Children  tax  the  patience  of  the  skiagra- 
pher  to  a  great  extent  because  they  find  it  very  difficult  to  keep 
their  arms  quiet.  Still,  as  the  skiagraphs  of  the  author  may  show, 
in  most  instances  a  fairly  good  reproduction  is  obtained,  if 
patience  is  exercised. 

Irradiation  should  also  be  done  perpendicularly,  the  joint  itself 
being  regarded  as  the  centre,  and  the  tubal  focus  being  right 
above  it. 

A  good  skiagraph  of  the  shoulder- joint  is  best  obtained  from 
the  posterior  aspect,  if  the  plate  is  kept  very  close  to  the  scapula, 
the  patient  being  in  the  recumbent  position. 

If  the  Wehnelt  interrupter  is  used,  children  require  about  one 
and  a  half,  thin  adults  two,  and  stout  adults  three  minutes' 
exposure. 

If  the  anterior  aspect  of  the  shoulder  is  skiagraphed,  the  sig- 
moid form  of  the  clavicle  must  appear  well  marked.  The  triangu- 
lar shadow  of  the  scapula  can  be  well  differentiated  from  that  of 
the  ribs.  Its  spine  can  be  followed  in  its  course,  running  parallel 
to  the  clavicle,  and  ending  at  the  acromion.  The  acromio-clavicu- 
lar  junction  shows  a  hiatus  which  in  the  early  days  of  skiagraphy 
was  mistaken  for  a  diastasis  of  the  joint.  An  increased  knowledge 
has  taught  that  this  apparent  diastasis  is  by  no  means  pathological, 
and  that  there  is  a  normal  gap  between  the  osseous  ends  of  the 
178 


SHOULDER    AND    UPPER    EXTREMITY  170 

acromion  and  the  acromial  end  of  the  clavicle.  The  glenoid  cav- 
ity, containing  the  head  of  the  humerus,  and  the  major  and  minor 
tubercula  should  also  be  well  marked  (see  Figs.  126  and  127). 
Between  the  clavicle  and  the  scapular  spine  appears  the  dark 
shadow  of  the  coraeoid  process  (Fig.  124).  For  structural  details 
the  diaphragm  is  absolutely  necessary.  The  compression  dia- 
phragm, however,  is  contraindicated  in  certain  injuries,  if  there 
is,  for  instance,  much  effusion  in  the  shoulder-joint  or  consider- 
able inflammation,  which  would  make  its  use  intolerable  to  the 
patient. 

Skiagraphy  of  the  scapula  is  indicated  in  tumours,  especially 
in  osteosarcoma. 

Tumours  of  the  clavicle  can  be  differentiated,  and  atrophy  of 
the  clavicle  in  aortic  aneurysm  represented  by  skiagraphy.  The 
true  character  of  pulsating  tumours,  erroneously  taken  for  sub- 
clavian aneurysm,  may  also  be  shown  (see  Fig.  631).  Tuberculous 
foci  are  sometimes  found  in  the  clavicle.  It  is  needless  to  say  that 
dislocation  of  the  clavicle  is  easily  differentiated  from  fractures 
by  the  aid  of  the  rays. 

SHOULDER-JOINT 

As  to  fractures  of  the  shoulder,  see  Fig.  68. 

Fractures  of  the  clavicle  are  usually  recognised  easily,  but  there 
are  cases  of  impaction  and  fissure  in  which  no  deformity  or  crepita- 
tion is  observable,  and  which  could  not  be  recognised  except  by  the 
aid  of  the  rays.  In  case  of  extensive  displacement,  it  is  important 
to  control  the  treatment  by  repeated  observations. 

Indeed,  the  shoulder-joint  was  formerly  regarded  as  a  real 
crux  medicorum.  While  dislocation,  for  instance,  should  be  easily 
differentiated,  by  the  possibility  of  palpating  the  joint-surface 
of  the  shoulder,  there  are,  in  fact,  many  unrecognised  cases. 

Fig.  123  shows  deformed  union  after  fracture  of  the  surgical 
neck  in  a  girl  of  fifteen  years  who  fell  from  a  window  in  the  fourth 
story.  The  force  of  the  fall  fortunately  was  broken  by  wash-lines 
strung  below,  so  that  the  patient  escaped  with  an  extensive  contu- 
sion of  the  right  foot,  a  wound  of  the  length  of  6  inches  at  the 
frontal  region,  and  a  fracture  of  the  surgical  neck  of  the  right 
humerus.  The  competent  family  physician  reduced  the  fragments 
at  once,  but  they  slipped  out  again ;  five  weeks  later,  when  the  an- 


180 


THE    EONTGEN    EAYS 


thor  saw  the  case  for  the  first  time,  a  protrusion  of  the  lower  frag- 
ment was  noticed,  which  was  united  to  the  small  upper  fragment 
in  juxtaposition.  It  was  a  surprise  to  find  that  in  spite  of  the 
immense  deformity  there  was  hardly  any  functional  disturbance 


at  the  time.  Osteoclasis,  however,  was  performed,  which,  while 
not  restoring  the  fragments  to  a  faultless  position,  brought  them 
into  apposition. 

This  again  shows  that  the  significance  of  a  skiagraph  for  the 


SHOULDER    AND    ri'l'KK    KXTKKMITY 


181 


purpose  of  estimating  the  degree  of  functional  disability  is  not 
always  conclusive.  (See  Chapter  XVII  on  Medico-Legal  Aspects.) 
Fig.  124  illustrates  the  case  of  a  fracture  of  the  surgical  neck 
of  the  humerus  in  a  girl  of  twenty-four  years,  who  was  first 
treated   for   a   contusion,    later    for    rheumatism.      Two    months 


Fig.  124  — Impacted  Fracture  of  the  Surgical  Neck  of  the  Humerus. 


after  the  injury  had  taken  place  a  slight  swelling  could  be  no- 
ticed round  the  shoulder,  especially  at  the  area  of  the  surgical  neck 
of  the  humerus,  but  no  signs  of  fracture  could  be  elicited.  The 
disturbance  of  function  was  insignificant,  the  patient  being  able 
to  elevate  her  arm  considerably.     There  was  occasional  pain  and 


182 


THE    EONTGEN   EAYS 


weakness.  The  skiagraph  revealed  the  presence  of  an  impacted 
fracture  of  the  surgical  neck  of  the  humerus.  The  impaction  ex- 
plains the  absence  of  crepitus  and  false  mobility,  which  may  serve 

as  an  excuse  for  not  hav- 
ing recognised  the  injury 
in  its  true  light. 

By  studying  the  skia- 
graph one  should  assume 
that  the  protruding  por- 
tion of  the  diaphyseal 
fragment  could  be  pal- 
pated through  the  deltoid 
muscle,  but  the  author 
did  not  succeed  in  doing 
so.  This  is  another  proof 
of  the  fact  that  palpation 
of  deep  tissues  is  not 
only  difficult,  but  its  re- 
sult frequently  imagi- 
nary. 

Similar  conditions 
were  observed  in  the  case 
of  a  man  of  fifty  years 
who  had  sustained  the  same  fracture  type  six  months  before  the 
skiagraph  was  taken  (Fig.  125).  The  diagnosis  was  contusion, 
the  patient  being  discharged  from  the  hospital  a  few  weeks  after 
the  injury  occurred.  There  was  considerable  disturbance  of  func- 
tion, which  was  attributed  to  the  atrophy  of  the  deltoid  muscle, 
developing  a  few  months  afterward.  The  skiagraph  showed  the 
humeral  head  united  to  the  diaphysis  in  an  oblique  direction. 
After  having  studied  the  skiagraph,  the  author  was  able  to  pal- 
pate the  protruding  portion  which  had  escaped  his  notice  before. 

Attention  is  called  to  the  irregularity  of  the  articular  surface 
of  the  scapula,  indicating  osseous  atrophy,  which  went  hand  in 
hand  with  the  atrophy  of  the  soft  tissues. 

In  a  case  of  this  kind  osteotomy  should  be  considered,  espe- 
cially if  the  patient  is  poor  and  has  to  live  from  the  income  of 
his  manual  labour. 

Just  as  in  'intrascapular  and  extrascapular  fracture  of  the  head 
of  the  femur  the  Eontgen  rays  show  that  in  fracture  of  the  head 


Fig.  125 


-Deformed   Fracture  of  Surgical 
Neck  of  Humerus. 


SHOULDER    AND    UPPKK    KXTREMITY 


183 


of  the  humerus,  schematic  distinction  between  the  fracture  of 
the  anatomical  and  surgical  neck,  as  well  as  transtubereular  frac- 
tures, cannot  always  be  made.  In  the  case  of  a  woman  of  fifty-six 
years  this  was  well  illustrated.  The  patient  had  fallen  about  five 
weeks  before,  striking  the  right  elbow  on  the  pavement.  There 
had  been  ecchymosis  at  the  elbow  at  the  time,  suggesting  a  frac- 
ture there,  but  no  fracture  had  been  found  at  this  point.  When 
examined  four  days  later  there  had  been  absolutely  no  objective 
symptoms  of  fracture  except  a  slightly  abnormal  mobility  in  the 
region  of  the  head  of  the  humerus.  The  pain  there  was  intense. 
There  was,  however,  no  swelling  or  deformity.  The  skiagraph 
(Fig.  126),  taken  in 
the  antero  -  posterior 
projection,  showed  a 
fissure  line  running 
downward  and  inward 
from  the  tubercles  to 
about  the  surgical  neck 
of  the  humerus.  An- 
other skiagraph  ( Fig. 
127),  taken  two  weeks 
later,  and  viewing  the 
bone  from  the  back, 
showed  a  line  that 
might  lead  one  to  look 
upon  the  case  as  one  of 
fracture  of  the  ana- 
tomical neck.  The  sec- 
ond skiagraph  showed 
chips  of  bone — a  con- 
dition that,  as  men- 
tioned before,  is  not  in- 
frequently met  with  in 
other  cases  supposed  to 
be  only  examples  of 
contusion.  When  such 
chips  of  bone  can  be  recognised,  the  massage  treatment  for  sprains 
is  manifestly  inappropriate. 

To  avoid  erroneous  interpretations,  the  fact  must  also  not  be 
lost  sight  of  that  the  union  between  the  epiphysis  and  the  diaphy- 


Fig.  126.— Anterior  View  of  Shoulder.     (Com- 
pare Fig.  127. ) 


184 


THE    KONTGEN    RAYS 


sis  of  the  head  of  the  humerus  is  not  perfect  before  the  twen- 
tieth year. 

As  a  counterpart  the  case  illustrated  by  Fig.  128  may  serve. 
It   represents  the   shoulder- joint  of  a  lady  of   fifty-eight   years, 


Fig.  127.— Fracture  of  the  Anatomical   Neck   of  the  Humerus,  Posterior 
View.     (Compare  Fig  126.) 

who,  after  having  fallen  from  a  chair,  had  her  arm  forcibly  pulled. 
Shortly  afterward  a  swelling  was  noticed  around  the  shoulder, 
and  a  fracture  suspected.  Immobilization  was  kept  up  for  two 
months.  The  skiagraph  revealed  the  absence  of  a  fracture  and 
the  presence  of  an  ankylosis,  probably  due  to  an  inflammatory 
process,  the  shadows  of  both  articulation  surfaces  running  into 
each  other.  Bloodless  breaking  up  of  the  adherent  area  is  indi- 
cated in  such  a  case. 

The  shaft  of  the  humerus  is  best  examined  while  the  patient 


SHOULDER    AND    [JPPER    EXTREMITY 


L85 


is  seated  on  a  low  chair,  his  extended  and  slightly  flexed  arm  rest- 
ing on  the  examining  table.  As  a  rule  a  general  view  suffices;  for 
structural  details  the  diaphragm  may  be  employed.  Especially  if 
there  are  thick  muscular  layers,  or  in  case  of  osteomyelitis  necrosis3 
or  osseous  cyst,  it  is  desirable  to  obtain  well-defined  outlines. 

In  children  immobilization  during  exposure  is  obtained  best  by 
the  diaphragm.  Or  a  small-sized  plate  is  fastened  to  the  humerus 
by  a  gauze  bandage.  Short  exposures  should  be  given  whenever 
possible ;  of  course  if  the  exposure  lasted  a  few  seconds  only  struc- 
tural details  cannot  be  expected.  The  bone  also  appears  light  then, 
because  a  soft  tube  cannot  be  selected  for  rapid  skiagraphy.    Fig. 


Fig.  128.— Fibrous  Ankylosis  of  Shouldeb. 


129  illustrates  the  fracture  of  the  diaphysis  in  a  new-born  child. 
Although  the  exposure  lasted  a  few  seconds  only,  the  fracture-line 
and  the  angular  as  well  as  the  axial  displacement  of  the  fragments 
are  well  represented.     The  focus  of  the  tube  being  situated  right 


186  THE    RONTGEN    EAYS 

above  the  humerus,  it  is  appreciated  why  this  area  appears  light, 
while  the  other  areas  show  a  darker  tint. 

As  to  dislocation,  it  is  generally  assumed  that  in  the  frequent 
subcoracoid  type  the  flattening  of  the  shoulder,  the  axial  change, 


Fig.  129.— Fracture  of  the  Diaphysis  of  the  Humerus  in  a  Baby,  sustained 
during  Labor.     (Rapid  exposure.) 

and  the  flat  prominence  of  the  anterior  aspect  of  the  axillary 
region  should  be  sufficient  indications  of  its  presence.  In  the 
subglenoid  (axillary)  variety  a  diastasis  between  the  head  of  the 
humerus  and  the  acromion  is  observed.  Thus  differentiation  ap- 
pears to  be  easy  from  a  theoretical  standpoint.  But  practical  ex- 
perience shows  that  in  spite  of  these  symptoms  many  diagnostic 
errors  occur  in  this  direction.  Fig.  130  shows  a  case  of  old  sub- 
coracoid dislocation  in  a  man  of  forty-three  years,  who  was  run 
over  six  months  before  the  skiagraph  was  taken  after  operation. 
He  was  treated  for  contusion  of  the  shoulder  for  that  length  of 
time.     On  examining   for  the   first  time  the   author   found  the 


SHOULDEK   AND    OTPEE    EXTEEMITY  187 

shoulder  much  flattened  and  the  acromion  unduly  prominent!  The 
joint  cavity  was  empty  and  the  head  of  the  humerus  could  be 
palpated  in  MohreTiheim's  groove.  The  arm  was  slightly  short- 
ened, the  motion  of  the  arm  greatly  impelled,  and  the  patient  suf- 
fered from  intense  periodical  pain,  which  seemed  to  be  dependent 
upon  nerve-pressure. 

The  Kontgen  rays  revealed  the  typical  signs  of  subcoracoid  dis- 
location. At  the  anterior  surface  of  the  neck  of  the  scapula  a 
thickened  area  was  noticed,  which  made  the  author  suspect  that 
there  was  a  co-injury  of  this  portion,  but  the  skiagraph  showed  the 
bones  to  be  intact.     As  the  operation  proved  afterward,  the  thick- 


Fiq.  130. — Wiring  of  Humeral  Head  to  the  Acromion  for  Old  Subcoracoid 

Dislocation. 

ened  portion,  which  might  have  corrresponded  to  callus  forma- 
tion, was  caused  by  the  presence  of  fragments  of  the  glenoid  cap- 
sule, which  had  formed  an  irregular  mass. 

After  various  methods  of  reduction  were  tried  in  vain  under 
anassthesia,  a  nearly  semilunar  incision  was  made  which  began  at 


188 


THE    RONTGEN    RAYS 


the  acromion,  and  running  over  the  intertubercular  sulcus  was 
extended  vertically  alongside  the  anterior  surface  of  the  arm. 
Thus  both  the  joints  and  the  acromion  were  exposed.  After  care- 
ful and  extensive  dissection  of  adhesions  the  author  succeeded  in 
rotating  the  head  of  the  humerus  in  its  glenoid  cavity.  There 
was  a  pronounced  tendency  to  forward  displacement  which 
could  not  be  overcome  by  additional  exposure.  Therefore,  the 
author  fastened  the  head  of  the  humerus  in  the  cavity  by  suturing 


Fig.  131.— Subcokacoid  Dislocation  of  Humerus. 


it  to  the  acromion  after  having  drilled  a  hole  through  the  head 
of  the  humerus.  On  boring,  the  head  was  found  to  be  very  soft, 
a  fact  which  was  also  illustrated  by  the  light  shadow  of  the  skia- 
graph. The  skiagraph  (Fig.  130)  taken  two  weeks  after  the  opera- 
tion, showed  the  humerus  in  good  position.  Recovery  was  perfect. 
It  seems  to  the  author  that  this  procedure  is  far  preferable  to  the 
resection  of  the  head  of  the  humerus,  as  advised  by  so  many  sur- 
geons. No  force  being  required,  laceration  of  muscles,  blood- 
vessels, and  nerves  is  avoided. 

In  a  case  of  habitual  dislocation  of  the  shoulder  similar  steps 
were  taken  (see  New  York  Medical  Journal,  July  14,  1903). 


SHOULDER    AND    [JPPER    EXTREMITY 


IS!) 


Fig.  132. — Greenstick  Feactuke  of  Humerus. 


Fig.  131  shows  subcoracoid  dislocation  in  a  woman  of  sixty-five 
years.  Although  five  weeks  had  elapsed  since  the  injury  was  sus- 
tained, reposition  was  successful,  prolonged  rotatory  motions  pre- 
ceding the  reducing  efforts. 


190 


THE    KONTGEN    RAYS 


In  periostitis  or  osteomyelitis  of  the  humerus,  a  preceding 
trauma  is  often  reported,  just  as  in  osteosarcoma.  The  pain,  the 
oedema,  the  fever,  and  the  general  debility  may  he  sometimes  so 
little  marked  that  differentiation  becomes  difficult.  Such  diffi- 
culty of  diagnosticating  this  disease  is  not  only  removed  by  the 
skiagraph,  but  a  trustworthy  guide  for  the  operative  technique  is 
furnished  at  the  same  time.  In  the  case  of  the  girl  described  in 
Chapter  XIII  on  Osteomyelitis,  the  slow  onset  of  the  symptoms 

did  not  seem  to  be  in 
favour  of  an  acute  in- 
flammatory process.  Pain 
being  present  only  tem- 
porarily, the  fear  of  a 
malignant  growth  was 
apparently  not  unjusti- 
fied. The  skiagraph  at 
once  did  away  with  all 
anxiety,  since  it  justified 
the  presence  of  a  eircum- 
scribed  osteomyelitic 
focus. 

Fracture  of  the  Shaft 
of  the  Humerus. — While 
fractures  of  the  shaft  of 
the  humerus  are  usually 
well  recognised  without 
the  aid  of  the  rays,  there 
are  some  details  that 
cannot  be  ascertained 
without  them.  Fig.  132 
illustrates  a  greenstick 
fracture  in  a  lad  of  nine 
years.  The  skiagraph 
showed  that  the  axis  of 
the  humerus  was  bent. 
This  knowledge  enabled 
the  author  to  redress  the  fragments  into  their  proper  direction 
three  weeks  after  the  injury,  the  character  of  which  was  not  recog- 
nised. Still,  who  has  never  been  guilty  of  misinterpreting  some  of 
these  injuries  ?  Aside  from  differentiation  between  preglenoid  and 


Pig.  133. — Fracture  of  the  Diaphtsis  of  the 
Humerus,  non-united  aftek  Nine  Weeks. 


SIIOULDKK    AND    UL'PEB    EXTREMITY 


191 


subglenoid  dislocation  and  fracture  of  the  anatomic  neck  of  the 

humerus,  there  remain  the  various  inflammatory  processes — 
traumatic,  rheumatic,  arthritic,  syphilitic,  and  tuberculous — and 
the  tumours,  like  en- 
chondroma,  osteoma, 
and  osteosarcoma.  Os- 
teosarcoma can  be 
recognised  at  an  early 
stage.  It  should  well 
be  borne  in  mind  that 
most  cases  of  osteo- 
sarcoma give  a  his- 
tory of  a  preceding 
injury,  so  that  the 
swelling  is  sometimes 
erroneously  taken  for 
callus  proliferation 
(see  Chapter  XIV). 

The  healing  proc- 
ess in  fractures  can 
be  well  studied  in  Figs. 
133  and  134,  which 
illustrate  the  case  of 
a.  lady  of  forty-five 
years  who  sustained  a 
transverse  fracture  at 
the  lower  third  of  the 
humerus  nine  weeks 
before  Fig.  133  was 
taken.  At  this  time 
the      fragments      had 

failed  to  be  united,  although  as  the  skiagraph  indicates,  callus 
tissue  was  present  in  moderate  quantity.  Where  the  cortex  of  the 
outer  portion  of  the  lower  fragment  joined  the  medulla  of  the 
upper  fragment  no  consolidation  had  taken  place. 

It  was  obvious  to  shift  the  protruding  fragment  into  place  by 
inward  pressure  at  the  upper  and  outward  pressure  at  the  lower 
fragment.  This  procedure  resulted  in  perfect  recovery  seven 
weeks  thereafter.  The  function  of  the  arm  was  not  disturbed  at 
all  until  a  year  afterward  the  patient,  in  falling  downstairs  again, 


Fig 


134.—  Refracture   in  Case  illustrated  by 
Fig.  133. 


192 


THE    RONTGEN    RAYS 


sustained  a  fracture  at  the  same  place.    The  skiagraph  (Fig.  134), 
taken  the  day  after  the  injury  occurred,  shows  considerable  axial 


Fig. 


135. — Extreme    Displacement    causing    Diastasis    of    Fragments   and 
Muscular  Intervention. 


and  angular  displacement.  At  the  same  time  it  indicates  the 
presence  of  a  large  amount  of  ensheathing  callus,  which  encircled 
the  upper  fragment  to  such  an  extent  that  it  assumed  the  form  of 


SHOULDER  AXD  UPPER  EXTEEMITY     193 

a  socket.  The  lower  end  of  the  fragment  became  round  shaped 
accordingly.  Thus  it  scons  thai  while  thorough  apposition  was 
obtained  after  the  correction  of  the  first  injury,  consolidation  took 
place  by  ensheathing  callus  formation,  that  is  virtually  in  the 
same  way  as  it  does  if  the  fragments  are  in  juxtaposition.  Re- 
covery was  perfect  seven  weeks  thereafter. 

The  median  as  well  as  the  radial  nerve  may  become  lacerated 
by  the  splintering  of  the  hones.  This  requires  immediate  neu- 
rorrhaphy. Of  course,  the  nerve  fragments  cannot  be  represented 
by  the  rays,  but  the  location  and  the  character  of  the  fracture, 
the  displacement  and  eventual  diastasis  of  the  fragments,  in  con- 
junction with  the  symptoms  in  the  sphere  of  these  nerves,  estab- 
lish the  diagnosis  and  dictate  the  operative  steps.  (See  Chapter 
XVI  on  Operative  Treatment  of  Deformed  Fractures.) 

Fig.  135  illustrates  muscular  intervention  caused  by  excessive 
displacement  in  a  man  of  fifty  years.  The  diagnosis  could  be 
made  by  the  enormous  swelling,  the  intense  pain,  and  the  pressure 
symptoms  in  conjunction  with  the  skiagraph. 

ELBOW-JOINT 

The  Elbow-Joint  must  always  be  examined  in  at  least  two  dif- 
ferent positions — viz.,  in  pronation  and  supination.  In  pronation 
the  forearm  is  flexed  and  the  arm  elevated  up  to  a  level  with  the 
shoulder,  while  the  patient  is  seated  on  a  chair,  the  internal  con- 
dyle occupying  the  centre  of  the  plate  (Fig.  121).  In  supination 
the  patient  assumes  the  recumbent  position,  the  olecranon  occupy- 
ing the  centre  of  the  plate.  The  position  is  often  dictated  by  the 
subjective  condition  of  the  patient.  In  the  case  of  an  inflamma- 
tory process  or  in  certain  injuries  the  patient  is  not  able  to  place 
his  forearm  in  supination.  The  humerus  as  well  as  the  hand 
may  be  immobilized  by  means  of  sand-bags.  In  children  the  plate 
can  be  fastened  by  gauze  bandages.  The  vacuum  of  the  tube  must 
be  very  low,  considering  the  translucent  state  of  the  cartilaginous 
epiphyses.  An  exposure  of  one  to  two  minutes  is  required  if  soft 
tubes  are  chosen  then.  As  a  rule  the  diaphragm  is  indispensable 
in  the  examination  of  the  elbow-joint.  In  nervous  children  short 
exposures  may  be  resorted  to  if  other  means  fail,  but  important 
details  may  escape  notice  then.  Tubes  provided  with  a  cooling 
apparatus  are  especially  advisable  for  such  purposes. 
U 


194  THE    EONTGEKT   RAYS 

If  exposure  in  two  different  projection  planes  is  omitted  impor- 
tant fractures  above  the  condyles  may  be  overlooked.  The  same 
applies  to  the  fracture  as  well  as  to  the  isolated  dislocation  of  the 
radial  head. 

In  children  the  skiagraphic  anatomy  of  the  elbow-joint  may 
be  falsely  interpreted.  It  should  be  remembered  that  the  osseous 
nucleus  of  the  interior  of  the  capitulum  humeri  appears  between 
the  second  and  third  years.  Another  nucleus  shows  in  the  inter- 
nal epicondyle  at  the  fifth  year,  a  third  in  the  trochlea  between 
the  eleventh  and  twelfth  years,  and  soon  afterward  a  fourth  in  the 
internal  epicondyle.  The  nucleus  of  the  internal  epicondyle 
unites  with  the  diaphysis  between  the  sixteenth  and  twentieth 
years;  but  the  other  three  nuclei  form  a  synostosis  among  them- 
selves at  the  seventeenth  year,  then  constructing  the  uniform 
osseous  epiphysis  which  completes  its  synostosis  with  the  diaphysis 
at  about  the  twentieth  year. 

In  very  young  children  the  eminentia  capitata  appears  as  if 
entirely  severed  from  the  humerus,  although  the  relations  are 
normal.  The  explanation  of  this  important  phenomenon  is  that 
the  epiphyseal  tissues  are  not  sufficiently  ossified  to  produce  a 
shadow  on  the  plate.  If  these  points  are  not  thoroughly  consid- 
ered the  diagnosis  of  a  displaced  fracture  fragment  might  be 
erroneously  made.  The  lower  epiphysis  of  the  humerus  consists 
of  four  nuclei,  which  do  not  ossify  until  from  the  eighth  to  the 
seventeenth  year.  The  epiphysis  of  the  trochlea  and  of  the  ole- 
cranon do  not  ossify  until  between  the  seventh  and  the  twelfth 
year,  which  explains  why  an  osseous  nucleus  is  still  connected  with 
its  neighbouring  epiphyseal  nuclei,  and  why  the  diaphysis,  con- 
nected by  cartilaginous  tissue,  appears  as  an  isolated  piece  of  bone, 
which  erroneously  may  be  taken  for  a  fragment. 

The  normal  relations  of  the  infantile  elbow  are  evident  from 
Fig.  136,  which  is  that  of  a  girl  of  four  years.  Six  weeks  before 
the  skiagraph  was  taken  fracture  of  the  external  condyle  was  sus- 
tained, which  accounts  for  the  enlargement  of  the  external  condyle 
and  the  outward  bending  of  the  ulna. 

It  must  also  be  borne  in  mind  that  in  fractures  in  childhood 
the  process  of  ossification  is  influenced  by  various  affections  of 
the  bone,  such  as  rachitis,  for  instance. 

As  stated  before,  inflammatory  processes  in  the  elbow-joint  are 
to  be  viewed  from  the  same  points  as  those  of  the  knee-joint. 


SHOULDER    AND    [JPP.ER    EXTREMITY 


195 


r 


The  elbow-joint  has  always  been  a  sun  ice  of  grief  to  the  medi- 
cal profession,  and  it  is  only  since  the  introduction  of  the  Rontgen 
rays  that  more  light  has  been  thrown  upon  the  injuries  of  this 
joint,  and  that  accord- 
ingly the  therapeutic 
results  have  become 
satisfactory. 

Most  text-books 
describe  a  number  of 
well-marked  signs  sup- 
posed to  be  character- 
istic of  the  various 
types  of  these  injuries, 
but  before  the  Ront- 
gen era,  the  final 
result,  and  since  the 
Eontgen  era,  the  skia- 
graphy result — 
showed  that  appar- 
ently even  the  simplest 
injuries  of  the  elbow 
were  misinterpreted. 

Koenig,  in  his 
classical  text-book  on 
Special  Surgery  (vol. 
iii,  1900,  p.  229), 
maintains  that  "  we 
are  but  rarely  able  to 
make  an  exact  ana- 
tomical diagnosis  of 
the  most  frequent 
types  of  fractures  of 
the  elbow."  This  dic- 
tum fortunately  cannot  be  substantiated,  since  irradiation  gives  us 
the  most  detailed  information.  It  is  unjustifiable  nowadays  to  at- 
tempt the  treatment  of  a  fracture  of  the  elbow  without  a  skiagraph. 
How  accurate,  in  fact,  an  anatomical  diagnosis  can  be  made  with 
the  rays  is  well  illustrated  by  the  following  cases : 

A  boy  of  five  years  fell  from  a  second-story  window,  sustain- 
ing an  injury  of  the  elbow.    Besides  a  few  insignificant  contusions, 


Fig.  136. — Well  United  Fracture  oe  the  Ex- 
ternal Condyle,  associated  with  Slight 
Downward  and  Inward  Displacement,  and 
with  Outward  Bending  of  the  Ulna,  the 
Relations  of  the  Infantile  Cartilages  being 
Normal. 


196  THE    BONTGEN"    RAYS 

there  was  a  fracture  of  the  external  condyle  of  the  humerus,  and 
special  surgical  care  was  recommended.  The  patient  was  trans- 
ferred to  a  hospital,  where  the  arm  was  immobilized  in  an  ex- 


Fig.  137.— External  Condyle  completely  turned  after  being  Fractured. 

tended  position.  After  five  weeks  the  patient  left  the  hospital 
because  his  general  condition  was  good,  and  the  swelling  about 
the  elbow  had  disappeared,  the  only  remaining  trouble  being  that 
the  elbow  could  not  be  flexed. 

When  the  author  examined  the  patient  at  this  time,  palpation 
revealed  a  bony  mass  near  the  lower  end  of  the  humerus  exter- 
nally, which  could  be  easily  moved  in  a  vertical  direction.  A 
skiagraphic  picture  taken  while  the  joint  was  resting  on  its  dorsal 
aspect  showed  the  presence  of  a  bony  fragment,  which  was  detached 
from  the  humerus  (see  Fig.  137).  The  space  between  the  upper 
articular  surfaces  of  radius  and  ulna  on  one  hand,  and  the  lower 
articular  surface  of  the  humerus  on  the  other,  seemed  to  be 
empty,  which  finds  its  natural  explanation  in  the  fact  that  the 
epiphyses  were  still  cartilaginous  in  this  young  patient,  and  there- 
fore translucent  by  the  rays. 

If  these  points  are  not  thoroughly  considered,  a  displaced  frag- 
ment might  be  assumed  where  normal  relations  exist. 

It  would  be  very  desirable  that  a  commission  of  surgeons 
should  classify  these  complicated  conditions  of  epiphyseal  ossifica- 
tion during  the  various  periods  of  development,  in  order  to  obtain 
authoritative  rules  for  the  text-books. 


SUOULDHIl    AM)    UPPER    EXTREMITY 


197 


A  second  skiagraph  was  taken  in  supination,  which  showed  the 
joint  in  lateral  projection,  so  that  the  fragment  appeared  some- 
what larger.  The  lower  cud  of  the  fragment  was  situated  directly 
below  the  integument,  which  presented  a  slight  prominence  in  pro- 
portion. At  first  the  author  intended  to  make  an  attempt  to  re- 
duce the  severed  fragment  and  suture  it,  and  with  this  purpose 
in  view  he  made  a  longitudinal  incision  above  it.  which  showed  it 
to  be  loosely  connected  with  the  surrounding  tissues.  The  articu- 
lar end  consisted  of  ihc  eminentia  capitata.  A  small  part  of  the 
trochlear  end  had  turned  towards  the  surface  of  the  epiphyseal 
fragment,  while  the  fractured  surface  of  the  small  fragment  ad- 
hered to  the  skin.  In  other  words,  the  fragment  had  turned  en- 
tirely around  on  its  own  axis.  Its  nutrition  seemed  to  be  so  much 
impaired   that   the   author   thought   it   wise   to   remove   it.      The 


Fig.  13S. — Supracondylar  Fracture  shortly  after  Reposition. 


largest  portion  of  the  fragment  consisted  of  cartilage  only,  a  small 
lateral  area  representing  real  osseous  tissue. 

It  hardly  needs  to  be  mentioned  that   after  the   removal  of 
the  fragment  the  arm  could  easily  be  flexed  without  any  forcible 


198 


THE    RONTGEN    EAYS 


efforts.  Recovery  was  uninterrupted.  After  a  week  passive  mo- 
tion was  begun,  and  the  final  result  was  perfect,  in  spite  of  the 
elimination  of  so  important  a  bone  section.    If  the  parents  of  the 


Fig.     139. — Supracondylar    Fracture     displaced     posteriorly    (Extension 

Fracture). 

patient  had  followed  the  instructions  of  the  family  physician  to 
ascertain  the  exact  anatomical  nature  of  the  injury  by  immediate 
irradiation,  the  torsion  of  the  fragment  would  have  been  recog- 
nised at  so  early  a  stage  that  reposition  might  still  have  been 
possible. 

Reposition  is  not  always  eas^y,  because  the  head  of  the  radius, 
by  being  pulled  forward  through  the  biceps  muscle,  favours  the 
displacement  of  the  fragments,  but  repeated  efforts  under  guid- 
ance of  the  Rontgen  rays  may  overcome  this  difficulty.  (As  to 
further  details  of  this  instructive  case,  see  Fortschritte  auf  dem 
Gebiete  der  Rontgenstrahlen,   September,  1902.) 

The  result  in  supracondylar  fracture  also  used  to  be  unsatis- 
factory because  the  direction  of  the  fracture-line  could  not  be 
recognised,  and  therefore  the  direction  towards  which  reposition 
had  to  be  attempted  was  only  guessed  at.  Thus  the  efforts  at  re- 
duction were  in  most  instances  only  partially  successful. 

Fig.    138   illustrates  the  supracondylar  fracture   of  a  boy  of 


SHOULDER    AND    OTPEK    EXTREMITY  199 

ten  years  shortly  after  reposition.  There  was  considerable  back- 
ward displacement,  the  recognition  of  which  enabled  the  author 
to  reduce  it  completely,  skiagraphic  control  through  the  plaster-of- 
Paris  dressing  verifying  the  successful  reduction  afterward.  It  is 
needless  to  emphasize  the  fact  that  such  skiagraphic  evidence 
proves  from  the  beginning  that  the  final  result  will  be  good,  while 
before  the  Eontgen  era  such  knowledge  was  only  gained  weeks 
afterward  when  the  gunstock  deformity  was  an  established  fact — 
when,  in  other  words,  it  was  too  late  for  correction. 

In  the  case  of  a  boy  of  six  years  who  had  sustained  a  similar 
injury  the  Eontgen  method  was  not  resorted  to  until  four  weeks 
after  the  injury  occurred.  As  Fig.  139  indicates,  there  was  an 
oblique  supracondylar  fracture,  followed  by  backward  displace- 
ment.    The  humeral  end  being  pressed  backward  during  the  fall 


Fig.    140.— Oblique   Supracondylar   Fracture    associated   with    Backward 
Displacement,  in  a  Baby  of  Six  Months. 

on  the  hand,  the  flexed  forearm  was  hyperextended  (extension 
fracture),  which  explains  that  in  cases  of  this  kind  the  oblique 
fracture-line  is  directed  from  behind  backward  and  downward. 
Attention   is  also   called  to  the  sharply  protruding  point  at  the 


200  THE    EOXTGEN    KAYS 

lower  end  of  the  diaphyseal  fragment,  which  offers  an  ohstacle  to 
flexion.  In  this  ease  it  was  too  late  to  correct  the  malunion  by 
force,  and  a  chisel  operation  had  to  he  suggested  therefore. 

In  Fig.  110  the  same  injury  is  illustrated  in  a  boy  of  ten 
months.  In  this  case  the  fracture  was  associated  with  epiphyseal 
separation.  Although  three  weeks  had  elapsed  since  the  injury 
had  occurred,  refracture  and  reduction  were  successful,  the  elbow 
of  the  anaesthetized  child  being  brought  to  the  edge  of  the  table, 


Pig.  141.  Supracondylar  Fracture. 

and  the  manipulations  being  made  in  a  longitudinal  direction. 
The  gunstock  deformity  disappeared  completely  then. 

Fig.  141  illustrates  the  case  of  a  boy  of  eleven  years,  whose 
supracondylar  fracture  was  mistaken  for  backward  dislocation. 
The  skiagraph,  obtained  three  days  after  the  fracture  occurred, 
demonstrated  that  the  protrusion  of  the  olecranon,  noticeable  in 
midst  of  the  swollen  elbow,  was  due  to  its  backward  displacement, 
which  was  produced  by  fracture.  The  enormous  swelling  pre- 
vented false  motion  and  crepitus,  hence  the  error.  It  is,  of  course, 
a  great  deal  more  difficult  to  reduce  the  fragment  in  a  swollen 
area,  as  it  was  in  this  case,  while  early  recognition  would  have 
made  reposition  easy. 

As  to  fracture  of  the  external  condyle  associated  with  lateral 
dislocation,  see  Fig.  13. 


SHOULDEK    AND    UPPER    EXTREMITY 


201 


Jn  regard  to  the  various  kinds  of  fractures  of  the  external  con 
dylc,  occurring  during  the  period  of  development,  the  reader  is  re 
ferred  to  the  author's  illustrations  in 
Fortschritte  auf  dem  Gebiete  der 
Rontgenstrahlen,  Band  v,  Hamburg. 
The  participation  of  the  radial 
nerve  is  discussed  in  the  chapter  on 
the  Operative  Treatment  of  De- 
formed Fractures.  An  extraordi- 
nary case  of  this  kind,  however,  may 
be  reported  in  this  connection. 

The  arm  of  a  girl  of  fourteen 
years  who  sustained  a  fracture  of  the 
external  condyle  of  the  humerus  by 
falling  from  a  high  stairway,  was 
immobilized  in  extension  by  an  ex- 
perienced surgeon.  Shortly  after- 
ward considerable  functional  dis- 
turbance set  in,  and  gradually  pa- 
ralysis of  the  extremity  developed. 
The  grasping  power  became  lost, 
and  supination  was  impossible. 
When  the  author  saw  the  patient 
for  the  first  time  there  was  considerable  deformity  in  the  region 
of  the  elbow  (Fig.  1-12)  and  the  typical  drop-hand.    Supination  of 

the  forearm  was  just 
as  impossible  as  ab- 
duction of  the  ulna 
(Fig.  143).  Both 
phalangeal  ends  could 
be  extended  slightly 
by  the  lumbricales 
and  interossei. 

Skiagraphic  exam- 
ination revealed  the 
presence  of  an  im- 
mense thickening  of 
the  external  condyle 
of  the  humerus,  which  pointed  to  an  injury  of  the  radial  nerve. 
This  suggested  the  presence  of  a  callous  mass  in  which  the  radial 


Fig.  142. — Old  Fractoke  of  Ex- 
ternal Condyle. 


Fig.  143.— Drop  Wrist,  due  to  Paralysis  of 
the  Radial  Nerve  caused  by  Fracture  of 
the  External  Condyle.    (See  Fig.  142.) 


202  THE    RONTGEN    RAYS 

nerve  was  buried.  Although  after  the  lapse  of  seven  years  recov- 
ery could  hardly  be  expected,  the  author  still  thought,  by  exposure 
of  the  nerve  and  resection  of  the  superfluous  bone  masses,  that  the 


Fig.  144. — Backward  Dislocation  of  Elbow. 

function  of  the  limb  might  be  materially  improved.  In  fact,  the 
radial  nerve,  when  exposed  by  a  longitudinal  incision,  showed  itself 
to  be  surrounded  entirely  by  osseous  tissue.  It  was  released  by 
extensively  chiselling  off  the  bone  masses.  The  considerable  im- 
provement of  the  symptoms  was  quite  surprising.  After  six  weeks 
the  result  was  further  improved  by  elongating  the  shortened  flexor 
tendons  by  tenoplasy.  The  hand,  which  had  formerly  hung  pow- 
erless, thus  regained  the  power  of  grasping. 

The  signs  of  supracondylar  fracture  often  resemble  those  of 
posterior  dislocation  of  the  elbow,  three  signs  being  common  to 
both  injuries — viz.,  shortening,  false  position,  and  the  axial  direc- 
tion. From  a  strictly  theoretical  point  of  view  it  seems  to  be  im- 
possible to  mistake  a  fracture  for  a  dislocation,  and  vice  versa. 
In  dislocation  the  flexor  side  of  the  forearm  and  the  extensor  side 
of  the  arm  are  shortened,  and  the  tendon  of  the  triceps  muscle 


SHOULDER  AND  UPPER  EXTREMITY 


203 


appears  like  a  small  arch,  the  concavity  of  which  is  directed 
towards  the  olecranon.  This  process  is  noticed  as  a  posterior 
projection  then.  The  trochlea  can  he  palpated  in  front  and  the 
outlines  of  the  joint  surface  of  the  head  of  the  radius  are  grasped 
in  the  back.  That  the  transverse  diameter  of  the  joint  always  re- 
mains normal  is  another  characteristic  feature  of  the  dislocation. 

In  spite  of  all  these  well-known  points  dislocation  is  often  mis- 
taken for  fracture,  and  vice  versa,  as  clinical  experience  shows. 
The  supracondylar  fracture,  illustrated  by  Fig.  141,  was  taken  for 
backward  dislocation  on  account  of  its  posterior  projection,  and 
the  backward  dislocation  illustrated  by  Fig.  Ill  was  regarded  to  be 
a  supracondylar  fracture. 

The  explanation  of  such  fatal  errors  is  given  by  the  presence 

of  considerable  swell-     

ing  which  prevents  ex- 
act palpation.  Still 
there  is  no  more  ex- 
cuse for  it  because  the 
rays  are  not  influ- 
enced by  the  swelling 
and  will  tell  the  exact 
truth,  thus  enabling 
the  surgeon  to  take 
the  proper  therapeu- 
tic steps.  The  author 
may  be  pardoned  for 
repeating  his  warn- 
ing so  often,  but  the 
"  Catonic  Ceterum 
censeo "  cannot  be 
emphasized  too  often 
in  this  connection. 
The  postero  -  medial 
type  of  dislocation  is 
of  rare  occurrence, 
but  may  also  be  mis- 
interpreted. Fig.  145  illustrates  a  case  of  this  kind  in  a  boy  of 
eleven  years.    The  reduction  was  easy. 

Fig.  146  is  a  sad  illustration  of  indifference.  A  labourer 
who  had  been  injured  by  a  machine  sustained  severe  injuries, 


Fig. 


145.  — Posteromedial    Discoloration 
Elbow. 


204 


THE    RONTGEN    EAYS 


which  were  interpreted  as  fracture  of  the  middle  of  the  humerus 
and  at  the  lower  third  of  the  ulna.  He  was  treated  hy  an  experi- 
enced surgeon  who,  relying  on  his  palpatory  talent,  did  not  care 
for  using  the  Rontgen  method.  The  treatment  of  the  humerus 
was  excellent,  the  fragments  having  been  held  in  exact  apposition, 
as  was  shown  by  the  skiagraph  taken  two  years  later.  The  ulnar 
fracture  had  not  been  well  reduced,  yet  it  is  improbable  that  the 


Fig.   U6. — Fracture  of  Cokonoid  Process   of   Ulna,  associated   with  For- 
ward Dislocation  of  Radius. 


deformity  of  that  bone  would  have  interfered  seriously  with  the 
function  of  the  arm.  But  in  the  elbow- joint  a  very  important 
lesion  was  shown,  which  had  not  been  detected  by  the  palpatory 
enthusiast.  The  man's  arm  eventually  becoming  paralyzed,  it  was 
thought  that  there  might  be  some  callus  proliferation  at  the 
humerus,  therefore  it  was  decided  to  free  the  nerve  by  operation. 
Still  the  condition  remained  unchanged.  If  at  that  time,  one 
year  and  a  half  after  the  injury,  skiagraphic  examination  had  been 


SHOULDER    AND    UPPER    EXTREMITY  205 

resorted  to,  no  such  operation  would  have  been  performed,  because 
the  picture  would  have  proved  the  absence  of  displacement.  This 
fact  would  have  excluded  the  possibility  of  compression  of  tin- 
nerve  at  this  point.  And  if  there  were  compression  of  the  nerve, 
the  skiagraph  would  have  pointed  to  the  respective  area. 

And  in  fact,  skiagraphy  of  the  elbow  revealed  the  presence  of 
fracture  of  the  coronoid  process  of  the  ulna  and  outward  disloca- 
tion of  the  radius.  Now,  if  the  Rontgen  method  had  been  resorted 
to  two  years  before,  it  would  have  shown  the  humerus  in  perfect 
and  the  ulna  in  a  displaced  position;  the  latter  would  easily  have 
been  averted  then  by  slight  inward  pressure.  The  radial  disloca- 
tion would  also  have  been  discovered,  and  could  have  easily  been 
reduced  at  that  time.  The  patient  is  still  paralyzed,  and  it  is  very 
questionable  if  he  will  recover.  It  is  true  that  we  are  all  liable 
to  error,  but  we  should  endeavour  to  correct  our  errors  as  soon 
as  possible,  and  not  procrastinate  two  years.  This  is  an  every-day 
example,  and  the  single  individual  is  not  to  blame  for  it,  because 
the  majority  still  follows  this  routine. 

The  injuries  of  the  upper  ends  of  the  radius  and  ulna  are  also 
to  be  regarded  as  important  factors  in  the  pathology  of  the  elbow- 
joint. 

In  considering  the  radius,  it  must  be  appreciated  that  the  frac- 
ture of  its  head  is  a  very  important  injury.  If  the  upper  fragment 
is  entirely  severed,  it  may  be  recognised  as  a  separate  piece  of  bone 
by  palpation.  In  addition,  it  will  not  share  the  motions  of  the 
arm,  while  alternately  turned  in  pronation  and  supination,  and  in 
that  case  crepitus  is  seldom  absent.  Intense  pain  may  point  to  the 
seat  of  the  fracture;  and  sometimes  it  may  be  guessed  by  simple 
inspection,  the  biceps  drawing  the  shaft  forward  and  causing  a 
slight  projection. 

But  whenever  there  is  entire  absence  of  displacement,  contu- 
sion or  distortion  may  be  thought  of.  This  error  is  apt  to  take 
place  so  much  easier  when  the  swelling  soon  following  the  injury 
veils  the  symptoms,  abnormal  mobility  especially  not  being  notice- 
able. In  former  years  it  was  only  under  anaesthesia  that  such  cases 
were  once  in  a  while  properly  diagnosticated. 

It  is  evident  that  the  diagnosis  of  fissure  of  the  radial  head  is 
still  more  difficult.  It  seems  to  the  author,  indeed,  that  until 
recently  its  presence  could  never  be  clearly  ascertained.  Fortu- 
nately, the  Rontgen  rays  throw  light  on  this  subject  as  well  as  on 


206  THE    RONTGEN"   RAYS 

many  others,  and  there  can  be  no  doubt  that,  with  our  increasing 
knowledge  and  experience,  fissure  of  the  radial  head  will  also  be 
recognised  more  frequently. 

The  following  case  may  serve  as  an  illustration :  it  is  one  which 
in  the  pre-Eontgen  era  would  surely  not  have  been  recognised  in 
its  true  nature. 

A  girl  of  twenty-four  years  of  age,  on  the  evening  of  October  4, 
1900,  in  falling  downstairs,  struck  her  right  elbow  against  a  piece 
of  iron  projecting  from  the  stairway.    She  called  upon  a  physician 


Fig.  147. — Fissure  of  the  Head  of  the  Radius. 

at  once,  who  found  the  elbow  much  swollen  and  painful.  No 
signs  of  a  fracture  were  then  detected. 

On  October  6th,  when  the  author  saw  the  patient  for  the  first 
time,  the  arm  was  in  right-angled  flexion,  and  the  region  of  the 
elbow-joint  showed  considerable  swelling  and  tenderness  equally 
distributed.  The  area  above  the  radial  head  showed  the  presence 
of  ecchymosis. 

A  skiagraph  was  taken  at  once  in  supination,  the  patient  lying 
on  her  back  (Fig.  147).  It  revealed  the  presence  of  fissure  of 
the  radial  head  beyond  any  doubt.  There  were,  in  fact,  two  dis- 
tinct fissure-lines,  one  running  through  the  circumferentia  articu- 


SHOULDER  AND  UPPER  EXTREMITY    207 

laris  alone  at  its  external  margin,  and  the  other  one  creating  a 
triangular  segment,  the  base  of  which  was  formed  by  the  internal 
margin  of  the  circumferentia  articularis  and  the  tip  by  a  splinter 
detached  from  the  radial  neck. 

The  therapy  consisted  simply  in  the  application  of  a  plaster-of- 
Paris  dressing  in  rectangular  flexion,  the  forearm  being  kept  in 
semipronation.  A  second  skiagraph,  taken  four  weeks  later, 
showed  ideal  union,  the  external  portion  of  the  circumferentia 
articularis  only  protruding  farther  than  it  should  normally.  It 
shows  also  how  quickly  the  evidence  of  the  presence  of  a  fissure 
becomes  lost  if  there  be  perfect  approximation — a  circumstance  to 
be  borne  well  in  mind  from  a  medico-legal  standpoint. 

The  function  of  the  forearm  did  not  become  perfect  until  three 
months  after  the  injury,  the  joint  showing  considerable  stiffness  at 
first,  which  yielded  gradually  to  massage  treatment. 

Fissure  of  the  radial  head  being  of  a  decidedly  intra-articular 
character,  an  effusion  in  the  joint  is  a  natural  sequence,  which  ex- 
plains the  uniform  swelling  at  the  beginning  as  well  as  the  stiff- 
ness at  a  later  period. 

From  the  study  of  this  case  we  may  learn  that  wherever  skia- 
graphy observation  shows  no  tendency  to  displacement,  it  will 
be  advisable  to  begin  motion  at  an  early  stage,  say  after  ten  days, 
in  fissure  as  well  as  in  fracture  of  the  radial  head.  In  relying  on 
the  skiagraphic  mentor,  our  results  will  be  far  superior  to  those  of 
the  past.  Even  in  the  much-feared  cases  of  fracture  of  the  radial 
head,  where  the  fragment  is  considerably  displaced,  a  great  deal 
can  be  done,  or  rather  prevented,  under  the  guidance  of  the  rays. 

In  the  case  of  a  man  of  thirty-two  years  of  age  the  author  had 
an  opportunity  to  diagnosticate  a  fracture  of  the  radial  head 
before  he  employed  the  Rontgen  rays.  This  was  easy  because  the 
much-displaced  fragment  was  freely  movable.  It  had  seemed  to 
the  author  that  he  had  succeeded  in  reducing  the  fragment,  but  a 
skiagraph  taken  twelve  hours  after  the  injury,  through  a  plaster- 
of-Paris  wire  splint,  showed  that  the  reposition  was  not  perfect. 
Anaesthesia  enabled  him  then  to  correct  the  displacement  perfectly 
in  the  half-extended  position.  The  result  was  very  satisfac- 
tory. 

Immobilization  should  be  kept  up  for  weeks  in  such  cases,  for 
premature  contraction  of  the  biceps  muscle  might  separate  the 
replaced  fragment.    If  the  fragments  are  not  properly  retained  in 


208  THE    EONTGEN    EAYS 

place,  the  production  of  extensive  adhesions  might  demand  resec- 
tion of  the  radial  head.  The  same  operation  might  be  indicated  if 
small  fragments  separated  from  the  cartilage  remain  detached  and 
act  like  foreign  bodies,  so  as  to  disturb  the  function  of  the  elbow. 
The  Eontgen  rays  enable  us,  in  the  event  of  this  rare  necessity,  to 
trace  out  the  mode  of  such  operations  definitely  beforehand. 

As  to  the  diagnostic  difficulties,  reference  is  made  to  Figs. 
239,  240  and  241,  described  in  the  chapter  on  Deformed  Frac- 
tures. As  to  fractures  of  the  olecranon,  see  Figs.  243  and  244  in 
chapter  on  Deformed  Fractures. 

It  was  thought  that  fractures  of  the  coronold  process  of  the, 
ulna  were  of  rare  occurrence.  But,  as  in  many  other  instances, 
experience  with  the  Eontgen  rays  has  taught  that  this  type  of 
fracture  is  much  more  frequent  than  was  formerly  believed.  By 
realizing  that  the  normal  coronoid  process  cannot  be  palpated 
through  the  thick  muscular  strata  that  protect  it,  the  difficulty  of 
making  out  the  broken  fragments  becomes  apparent.  The  strong 
lateral  ligaments,  as  well  as  the  annular  ligament,  which  is 
strengthened  by  the  brachialis  muscle,  form  so  strong  a  protection 
to  the  process  that  a  displacement  of  its  fractured  fragment  sel- 
dom takes  place.  This  usual  absence  of  displacement  also  explains 
why  crepitus  is  ordinarily  not  produced.  The  presence  of  ecchy- 
mosis,  as  well  as  of  intense  circumscribed  pain  in  the  cubital  fold 
produced  by  strong  flexion,  are  suspicious  signs.  The  latter  would 
indicate  that  the  process  is  pushed  into  the  fossa  anterior.  It 
should  not,  however,  be  forgotten  that  this  valuable  symptom  is 
entirely  of  a  subjective  nature. 

Thus,  a  positive  diagnosis  can  but  seldom  be  made  without 
using  the  Eontgen  rays.  The  diagnosis  will  also  determine  the 
prognosis.  If  there  is  but  little  tendency  to  displacement,  the 
prognosis  is  favourable  even  when  the  diagnosis  has  not  been 
made.  But  if  there  is  any  marked  displacement  the  function  of 
the  elbow  is  greatly  disturbed.  In  such  an  event,  of  course,  the 
diagnosis  is  so  much  easier  the  greater  the  displacement  is.  Now- 
adays this  much-dreaded  condition  need  not  be  feared,  since  repo- 
sition of  the  fragments  has  become  greatly  simplified  under  the 
guidance  of  the  rays. 

The  after-treatment  is  best  conducted  in  a  rectangular  dressing 
of  plaster  of  Paris.  In  the  cases  referred  to  the  fragments  were 
invariably  found  in  a  displaced  position,  so  that  they  projected 


SHOULDEE    AND    [JPPER    EXTREMITY  209 

into  the  joint,  interfering  with  free  motion.  The  projecting  bone- 
mass  therefore  had  to  be  chiselled  off.  (Compare  Fig.  L98  in 
Chapter  XIII   on  Arthritis.) 


FOREARM 

The  forearm  is  examined  after  the  same  principles  which  were 
emphasized  in  the  study  of  the  arm.  The  anatomical  relations  of 
this  region  are  more  favourable  for  irradiation,  because  the  hones 
are  near  the  integument  and  the  soft  tissues  arc  thin.  The  best 
reproductions  are  obtained  if  the  surface  extensor  is  placed  on 
the  plate,  for  the  reason  that  the  bones  are  situated  directly  under- 
neath the  skin  there.  In  spite  of  this  accessibility,  however,  it  is 
always  preferable  to  expose  in  two  different  projection  planes — 
viz.,  in  antero-posterior  or  postero-anterior  direction,  and  in  the 
lateral. 

Injuries  of  the  forearm,  the  extremity  used  for  working  as 
well  as  for  protecting  the  body — this  member  being  instinctively 
outstretched  when  one  is  afraid  of  falling — are  of  great  frequency. 
In  fracture  of  the  bones  of  the  forearm  thorough  adaptation 
of  the  fragments  is  essential  for  the  preservation  of  the  functional 
ability  of  this  important  part.  If  there  is  no  displacement  the 
course  is  naturally  not  disturbed.  No  reposition  being  necessary, 
the  therapy  consists  in  simply  applying  some  suitable  immobilizing 
apparatus.  The  author  prefers  the  plaster-of-Paris  dressing  here 
just  as  well  as  in  most  other  fractures. 

Fig.  148  illustrates  this  type.  Although  there  was  considerable 
splintering,  the  bones  remained  in  good  apposition,  so  that  no 
efforts  at  reduction  were  required.  The  patient,  a  labourer  of 
twenty-five  years,  suffered  considerably  and  showed  extensive 
swelling  around  the  fractured  area,  so  that  the  author  had  the 
impression  that  extensive  displacement  had  taken  place.  If  the 
Rontgen  rays  had  not  shown  the  fallacy  of  this  impression,  forcible 
efforts  at  reduction  would  have  been  made,  and  the  splinters  might 
have  been  dislodged,  so  that  the  same  hands  which  were  expected 
to  correct  and  heal  would  have  increased  the  severity  of  the  injury. 

How  far  the  correcting  tendency  of  nature  goes  is  evident 
from  Fig.  149,  which  illustrates  the  antibrachial  fracture  of  a  boy 
of  three  years.  For  two  months  no  medical  advice  was  sought, 
15 


Fig.  148. — Fracture  of  Both  Bones  or  the  Forearm.      210 


SHOULDER  AND  UPPER  EXTREMITY    211 

until  the  loss  of  the  power  of  pronation  and  supination  and 
the  protrusion  caused  by  the  formation  of  ensheathing  callus 
gave  the  impetus.  Apparently  the  fragments  were  not  displaced 
at  the  time  the  fracture  occurred.  Still  the  fact  that  no  immo- 
bilization was  attempted  explains  why  a  large  mass  of  ensheathing 
callus  was  thrown  out.  The  irritation  of  the  soft  tissues  produced 
adhesions  between  themselves  and  the  callus-masses,  which  ac- 
counts for  the  impossibility  of  pronation  and  supination.  Under 
anaesthesia  the  adhesions  were  destroyed.     In  such  neglected  cases 


Fig.   149. — Fracture   in   the  Middle  of  the   Forearm   in  a  Boy  of   Three 

Years. 


the  excessive  callus-masses  may  cause  synostosis  between  the 
two  bones,  although  there  was  no  displacement  at  all. 

Thus  we  see  that  in  fracture  of  the  bones  of  the  forearm  thor- 
ough adaptation  and  immobilization  of  the  fragments  is  essential 
to  preserve  functional  ability.  Fracture  of  either  the  radius  or 
the  ulna  alone,  when  perfect  coaptation  is  not  secured,  may  pre- 
vent supination  to  such  an  extent  that  the  unfortunate  patient 
may  be  unable  to  follow  his  occupation.  How  much  more  is  the 
functional  ability  impaired,  when,  after  fracture,  both  bones  unite 
in  false  positions,  with  overlapping  of  the  fragments  and  angular 
deformity. 

To  what  extent  the  Rontgen  rays  enable  us  to  overcome  some 
of  the  technical  difficulties,  even  in  desperate  conditions,  is  illus- 
trated by  the  following  case : 

Both  forearms  of  a  labourer,  aged  thirty-four  years,  were 
caught  in  the  wheel-strap   of  a   powerful   machine   and   broken. 


212 


THE    RONTGEN    RAYS 


The  patient  was  brought  to  the  hospital,  where  proper  efforts 
were  made  to  reduce  the  displaced  and  partially  splintered  frag- 
ments. 

At  first  reposition  seemed  to  have  been  successful,  and  the 
swelling  disappeared,  but  both  hands  remained  stiff  and  paralyzed, 
and,  excepting  the  thumbs,  were  without  sensation. 

Extensive  oedema  having  repeatedly  been  present  the  disturb- 
ance in  motion  as  well  as  in  sensibility  seemed  to  be  of  an  ischemic 
nature  rather  than  caused  by  a  direct  trauma  to  the  nerves.  The 
muscular  atrophy,  which  was  still  present,  also  pointed  to  the 
breaking  down  of  contractile  muscular  elements.  When  the 
author  saw  the  patient  for  the  first  time  he  found  angular  deform- 
ity, abnormal  mobility,  and  the  functional  disturbances,  described 
above,  on  both  sides. 

The  skiagraphs  of  both  forearms  showed  considerable  overlap- 
ping. In  the  right  forearm  overlapping  of  the  radial  fragments 
existed  in  the  middle  and  lateral  deviation  of  the  ulnar  fragments 
an  inch  below.  The  skiagraph  of  the  left  side  showed  the  overlap- 
ping of  both  sides,  and  also  the  formation  of  a  bone  bridge  between 


Fig.  150. — Displaced  Fracture  of  Radius  and  Ulna,  Producing  Synostosis. 


the  lower  fragments  of  the  ulna  and  the  upper  fragments  of  the 
radius,  which  alone  would  exclude  any  possibility  of  rotation 
(Fig.  150). 


SHOULDER    AND    UPPER    EXTREMITY  213 

First  an  attempt  was  made  to  correct  the  position  of  the  frag- 
ments of  the  right  forearm,  by  exposing  and  freeing  them. 
Under  the  guidance  of  the  skiagraph  a  semilunar  incision  in  an 


Fig   151.— Case  illustrated  by  Fig.  150,  after  Wiring. 

oblique  direction  was  made.  The  shortening  was  overcome  by 
resorting  to  forcible  extension.  The  fragments  were  then  united 
by  silver-wire  sutures.  The  modus  operandi  consisted  in  freeing 
the  old  adhesions  thoroughly  with  knife  and  chisel,  and  folding 
the  arm,  so  to  say,  completely.  By  encircling  the  two  antibrachial 
fragments  with  a  strong  bandage  the  folded  mass  could  be  steadied 
by  an  assistant,  so  that  the  necessary  holes  could  be  bored  (Fig. 
151).  As  shown  by  a  skiagraph,  taken  six  weeks  after  this  opera- 
tion, the  radial  fragments  were  in  ideal  apposition.  The  ulnar 
fragments  shoAved  slight  lateral  displacement,  while  the  callus- 
formation  had  assumed  so  fortunate  a  character  that  no  other 
depression  or  protrusion  remained. 

Five  days  after  the  first  operation  the  left-sided  fracture  was 
exposed  in  the  same  way.  In  spite  of  extensive  exposure  of  the 
fractured  area  the  fragments  could  not  be  forced  into  apposition 
except  by  shortening  them.  So  the  author  made  a  virtue  of  neces- 
sity by  giving  the  ends  of  the  fragments  a  triangular  shape,  which 
enabled  him  to  indent  them  into  each  other.  As  the  skiagraph 
showed,  taken  four  weeks  after  this  operation,  the  apposition  of 
the  radial  fragments  was  perfect.  The  ulna  did  not  show  lateral 
deviation,  none  of  the  medullary  lines  presenting  any  axial  diver- 


214 


THE    EONTGEN    EAYS 


gence.     The  skiagraph  showed,  however,  that  there  was  a  slight 
angle,  which  could  be  corrected  in  time  by  simple  pressure. 

Union  took  place  by 
first  intention  without  any 
reaction.  The  healing 
process  was  quicker  on 
the  left  side,  which  is  ex- 
plained by  the  absence  of 
wire  suturing.  To  be  sure 
that  consolidation  was  per- 
fect, the  author  immobil- 
ized the  arm  until  two 
months  after  operation, 
leaving  off  the  plaster-of- 
Paris  splint  temporarily 
for  the  employment  of 
massage.  The  final  result 
was  perfectly  satisfactory. 
Thus  we  see  how  the 
happy  era  of  combined 
asepsis  and  skiagraphy 
permits  of  the  correction 
of  even  the  most  exten- 
sive deformities  in  a  sim- 
ple and  safe  manner. 

From     a     theoretical 
point    of    view    it    should 
be    expected    that    on    ac- 
count of  the  more  abund- 
ant     callus  -  proliferation, 
induced   by   the   irritation 
of    the    wire    suture,    con- 
solidation would  be  quick- 
er    and     more    thorough. 
But    practice    proved    the 
contrary  in  this  instance, 
and  it  seems  to  the  author 
that  indentation  permits  of  more  accurate  adaptation  and  im- 
mobilization.   At  the  same  time  larger  surfaces  for  agglutination 
are  obtained,  and  the  soft  tissues  are  less  liable  to  be  disturbed. 


Fro.  152. — Fracture  of  Radial  Diaphtsis. 


SHOULDER  AND  UPPER  EXTREMITY     215 

Triangular  indentation  of  the  fragments  should  therefore  be  pre- 
ferred whenever  possible. 


Fig.  153.— Fracture  of  Radial  Diaphysis  after  Alleged  Reduction.     (Com- 
pare Fig.  152.) 

The  modus  operandi  for  indentation  is  practically  the  same  as 
demonstrated  by  Fig.  151. 


216  THE    RONTGEN    EAYS 

As  to  further  observations  on  important  injuries  in  this  region, 
see  chapter  on  Deformed  Fractures. 

Fracture  of  either  the  radius  or  the  ulna  are  generally  recog- 
nised without  difficulty.  Still,  as  Fig.  258  shows  (chapter 
on  Medico-Legal  Aspects),  fracture  associated  with  little  or  no 
displacement  might  be  easily  overlooked.  In  the  case  of  dis- 
placement the  radius  may  be  pressed  against  the  ulna,  so  that 
synostosis  takes  place,  an  event  which  would  render  rotation  im- 
possible. Fig.  152  illustrates  a  case  in  which  the  upper  radial 
fragment  was  pressed   against   the  ulna.     Reposition  was  made 


Fig.  154. — Fracture  of  the  Ulnar  Diaphysis. 

by  bending  the  forearm  in  the  same  manner  as  a  greenstick  is 
crossed  over  the  knee,  the  ulna  resting  on  the  edge  of  a  table. 

When  it  was  thought  that  reposition  was  perfect  a  plaster-of- 
Paris  dressing  was  applied.  But  the  skiagraph,  taken  at  once 
through  the  plaster,  showed  that  reposition  was  imperfect  (Fig. 
153);  therefore  a  second  effort  was  made,  which  proved  to  be  suc- 
cessful. In  such  cases  it  is  advisable  to  flex  the  opposite  bone  as 
much  as  possible — that  is,  in  isolated  radial  fracture  the  ulna,  and 
in  isolated  ulnar  fracture  the  radius,  must  be  bent. 

Fracture  of  the  ulnar  diaphysis  also  shows  a  great  tendency 
to  inward  displacement,  thus  causing  the  same  disturbances  ob- 
served in  fractures  of  its  fellow,  synostosis  rendering  pronation 
and  supination  impossible.  The  same  principles  apply  to  the 
correction  of  this  injury  as  those  emphasized  on  fracture  of  the 
radial  diaphysis. 

Fig.  15-1  illustrates  the  fracture  of  the  ulnar  diaphysis  of  a 
girl  of  eight  years.     "While  the  lower  fragment  did  not  come  in 


SMOULDER    AM)    DTPEK    EXTREMITY  217 

contact  with  the  radius,  it  still  protruded  so  far  that  it  impaired 
the  soft  tissues,  thereby  setting  up  an  inflammatory  process.  The 
result  would  have  been  excessive  callus-formation,  so  that  virtually 
the  same  conditions  would  prevail  as  if  the  ulnar  fragment  had 
ridden  on  the  inner  radial  surface.  It  is  evident  from  the  illustra- 
tion that  outward  pressure  must  force  the  fragments  in  place. 
To  hold  them  in  silu  the  rubber-drainage  splints  advised  for 
metacarpal  fracture  (see  Fig.  165)  arc  recommended  in  order 
to  avoid  recurrence  of  the  displacement.  Attention  is  called  to 
the  bending  of  the  radial  diaphysis,  which  would  be  permanent  if 
it  was  not  corrected  synchronously  with  the  reposition  of  the 
ulnar  fragments.  In  adults  such  bending  is  not  found,  the  force 
applied  to  the  ulna  generally  being  sufficiently  strong  to  fracture 
its  fellow. 

WRIST 

No  bone  of  the  human  skeleton  is  so  great  a  source  of  trouble 
for  the  practising  physician  as  the  radius,  and  especially  its 
lower  end.  If  it  is  only  appreciated  that  fracture  of  the  carpal 
end  of  this  bone  is  the  most  frequent  fracture  type — at  least  18, 
but  perhaps  22  per  cent  of  all  fractures — its  importance  is  well 
understood. 

The  old  dictum,  "  Qui  bene  diagnoscit.  bene  medebitur," 
applies  preeminently  to  the  treatment  of  this  fracture,  generally 
known  as  Colles's  fracture.  In  fact  the  laws  that  govern  the  treat- 
ment of  this  much-disputed  injury,  and  last  but  not  least  the  final 
results,  are  entirely  determined  by  a  correct  diagnosis.  The  prin- 
ciples of  treatment  are  then  reduced  to  a  few  points  of  simple  com- 
mon sense. 

Such  complete  and  correct  diagnosis  could  not.  as  a  rule,  be 
made  before  Rontgen's  great  discovery.  It  can  safely  be  main- 
tained that  in  most  cases  skiagraphy  has  revealed  conditions  that 
were  not  expected,  and  required  the  original  diagnosis  to  be  more 
or  less  modified. 

The  questions  most  frequently  asked  of  a  surgeon,  "  How  do 
you  treat  Colles's  fracture  ?  "  "  Do  you  use  long  or  short  splints  ?  " 
"  Do  you  prefer  the  plaster-of-Paris  dressing  or  a  splint  ?  "  "  Are 
you  for  Dumreicher's,  Eoser's,  Schede's,  Braatz's,  Gordon's, 
Koelliker's,  Moore's,  Carr's,  Bond's,  or  Middledorpf's  bilateral, 


218  THE    KONTGEN"    EAYS 

or  for  the  old  pistol  splint  of  Nekton  ?  "  "  Are  you  in  favour  of 
immobilization  or  of  early  motion  ?  "  etc.,  show  that  the  essential 
points  are  generally  overlooked,  fracture  of  the  lower  end  of  the 
radius  being  regarded  by  many  as  a  constant  type,  uniformly 
characterized  by  the  fracture  of  the  bone  an  inch  above  the  articu- 
lation, and  followed  by  a  silver-fork-shaped  deformity  of  the  wrist. 
This  point  of  view  is  inadequate  and  erroneous.  It  has  been 
found  that  the  anatomical  aspects  of  the  various  forms  of  frac- 
ture of  the  lower  end  of  the  radius  differ  in  fact  more  than  those 

of  any  other  fracture,  and  it  is  self- 
evident  that  such  variants  must 
greatly  influence  the  manner  of 
treatment. 

In  the  first  place,  the  question 
whether  the  fracture-line  is  intra- 
articular   or    extra-articular    is    of 
great    importance,    because    for    a 
simple  extra-articular  fracture  and 
a  Y-shaped  intra-articular  fracture 
different    therapeutic    means    must 
be  sought.     Again,  the  varying  re- 
lations of  the  fracture  of  the  radius 
to  its  fellow,  the  ulna,  influences 
the  plan  of  treatment  considerably. 
It     is     but     natural     that     our 
Fig.   155.— Fracture  of  Radius,    therapy    should    be    changed    and 
Upward    Bayonet-shaped    Dis-    directed     by     fuller     clinical     expe. 

PLACEMENT.  J  .  L 

rience  and  anatomical  observation. 
In  the  short  space  of  time  which  has  elapsed  since  Eontgen's 
discovery,  it  has  been  found  that  the  anatomical  aspect  of  the 
fracture  of  the  carpal  end  of  the  radius  (inaccurately  called 
Colles's  fracture)  shows  a  number  of  types.  It  is  true  that  the 
majority  of  cases  are  characterized  by  a  breach  of  continuity  from 
10-30  millimetres  above  the  articular  surface  of  the  carpal  epiphy- 
sis, which,  on  account  of  a  peculiar  turn  of  the  lower  fragment, 
causes  that  deformity  of  the  wrist  which  is  compared  with  a  fork 
(displacement  a  la  fourchette)  or  with  a  bayonet,  or  with  a  flat  Z 
(Fig.  155).  But  besides  this  type,  first  described  by  Colles,  there 
still  remains  a  large  group  differing  from  it  materially.  Without 
undervaluing  the  great  work  of  our  surgical  masters  before  the 


SHOULDER  AND  UPPEK  BXTEEMITY    219 

Rontgen  era,  and  particularly  commending  the  work  of  Nekton, 
Velpeau,  Volkmann,  and  Koenig,  we  must  still  say  that  the  rays 
furnish  the  most  convincing  proof  of  the  necessity  of  modifying 
their  interpretations  of  this  injury.  Thus,  having  regard  to  old 
experience  as  well  as  to  information  recently  gained,  the  author 
has  tried  to  classify  those  different  forms  of  this  much  disputed 
fracture  which  appear  to  be  most  characteristic,  and  must  ac- 
cordingly demand  different  therapeutic  measures;  and  if  we  bear 
in  mind  the  frequency  of  fractures  of  this  type,  and  believe  they 
represent  22  per  cent  of  all  fractures,  the  importance  of  a  detailed 
diagnosis  needs  no  further  argumentation. 

The  author  distinguishes  the  following  varieties  of  fracture  of 
the  lower  end  of  the  radius :  ( 1 )  Simple  extra-articular  fracture 
without  displacement  (Colles's  fracture)  ;  (2)  epiphyseal  (chon- 
dro-epiphyseal  and  osteo-epiphyseal)  separation;  (3)  fissure;  (4) 
simple  or  multiple  fracture,  with  displacement;  (5)  fracture  of 
the  carpal  end  of  the  radius  associated  with  fracture  of  the  styloid 
process  of  the  ulna;  (6)  fracture  of  the  carpal  end  of  the  radius 
associated  with  fissure,  fracture,  or  dislocation  of  the  lower  end 
of  the  ulna;  (?)  fracture  of  the  carpal  end  of  the  radius  associ- 
ated with  fissure  or  fracture  of  a  carpal  bone  (sometimes  also  with 
the  end  of  the  ulna).  The  last  six  varieties  may  be  intra-articular 
as  well  as  extra-articular;  (8)  fracture  of  little  bone  portions 
(chips),  generally  extra-articular. 

Simple  subcutaneous  fractures  showing  little  or  no  displace- 
ment often  heal  without,  or  in  spite  of,  any  treatment,  as  the 
long  sin-register  of  quackery  will  demonstrate.  The  number  of 
fractures  not  recognised  as  such  during  treatment  is  legion.  The 
treatment  in  such  cases  is  often  simply  a  question  of  comfort, 
which  may  be  obtained  by  encircling  the  wrist  with  a  bracelet  of 
moss-board. 

This  appliance  sufficiently  immobilizes  the  wrist  and  at  the 
same  time  permits  enough  motion  to  counteract  the  formation 
of  adhesions  in  the  sheaths  of  the  tendons.  The  patient  carries 
his  hand  in  a  sling  in  such  a  manner  that  the  ulnar  margin  rests 
on  it.  Thus  free  motion  of  the  hand  is  permitted.  The  patient 
is  told  to  move  his  fingers  as  in  playing  the  piano ;  and  the  author 
finds  it  very  useful  to  advise  him  to  grasp  marbles  of  moderate 
size  and  to  roll  them  around  in  the  palm  of  the  hand.  Patients 
are  generally  willing  to  keep  these  marbles  in  their  pockets  and 


220  THE    RONTGEN    RAYS 

play  with  them  while  reading  or  conversing  or  walking  around. 
If  motion  is  thus  constantly  kept  up,  massage  treatment  as  well 
as  forcible  motion  can  be  dispensed  with,  and  recovery  is  perfect 
in  four  weeks,  or  sometimes  even  in  three.  Most  of  these 
fractures  being  extra-articular,  articular  effusion  is  generally 
absent. 

If  the  fracture-line  extends  into  the  joint,  displacement  usu- 
ally follows.  The  oblique  fracture  of  the  lower  end  of  the  radius 
has,  as  far  as  the  author's  knowledge  goes,  not  yet  been  described. 
The  author  has  observed  it  in  adults  only.  It  looks  as  if  the  frac- 
ture-lines were  longitudinal  at  the  articular  surface,  the  upper 
fragment  appearing  as  a  triangular  piece  of  bone.  The  apex  of 
this  piece  begins  about  an  inch  from  the  wrist,  while  the  base 
carries  part  of  the  joint  surfaces,  so  that  the  lower  as  well  as  the 
upper  show  articular  surfaces.  If  there  is  no  displacement,  the 
treatment  is  the  same  as  in  diaphyseal  separation,  or  complete 
fracture  without  tendency  to  displacement.  In  the  triangular  type, 
however,  in  view  of  the  intra-articular  inversion,  it  is  preferable 
to  apply  a  plaster-of-Paris  dressing  immediately  after  the  injury 
is  sustained.  (See  illustration  in  Journal  of  the  American  Medi- 
cal Association,  June  5,  1902.) 

But  whenever  displacement  of  the  fragment  takes  place,  accu- 
rate reposition  is  the  conditio  sine  qua  non. 

Then  the  modus  operandi  of  reduction  depends  upon  the 
type  of  displacement.  In  the  majority  of  cases  the  lower  frag- 
ment is  directed  upward,  so  that  there  is  dorsal  prominence,  the 
joint  not  being  concerned.  In  such  cases  (generally  called 
typical  Colles's  fracture)  the  shape  of  the  deformed  wrist  resem- 
bles that  of  a  bayonet  or  a  fork  (Fig.  155).  The  Rontgen  rays 
have  shown,  however,  that  the  upward  displacement  as  a  rule  is 
associated  with  sideward  displacement,  generally  in  an  outward 
direction,  causing  radial  inversion,  and  consequently  slight  short- 
ening of  the  radial  axis.  In  such  cases  the  clinical  diagnosis  is 
not  difficult.  The  lower  fragment  pushes  towards  the  dorsum, 
at  which  a  prominence  is  seen,  near  the  wrist,  corresponding  to 
a  groove  at  the  site  of  the  upper  end  of  the  fragment.  The  upper 
(diaphyseal)  fragment  presses  against  the  flexors,  producing  a 
prominence  further  upwards.  The  greater  the  prominence,  the 
shorter  is  the  radial  axis.  Crepitus  is,  even  in  these  typical  cases, 
often  absent.     In  a  number  of  cases,  however,  the  direction  of 


SHOULDEK    AND    CTPPER    EXTREMITY 


221 


the  displacement  is  found  to  be  towards  the  ulna,  even  if  the 
diaphysis  is  not  pronated. 

There  are  also  a  number  of  eases  observed  by  the  author  ;i> 

well  as  by  others  where  the  lower  fragment  is  turned  backward 
around  the  transverse  axis.  Sometimes  the  sagittal  axis  of  the 
lower  fragment  is  turned  around.  The  oblique  type  (triangular 
fragment),  in  which  the  joint  surface  is  split,  has  been  spoken  of 
above.  A  rare  form  is  the  detachment  of  the  posterior  border  of 
the  joint  surface.     Roberts  also  observed  forward  displacement  of 


Fig.  1o6. — Fracture  of  Lower  End  of  Radius,  showing  Upward  and  Inward 
Displacement  and  Outward  Bending  of  Ui.na. 


the  fragments.  Most  of  these  forms  can  only  be  diagnosticated  by 
the  Rontgen  rays. 

By  being  upwardly  dislodged,  the  lower  fragment,  in  typical 
cases,  is  brought  into  slight  supination,  while  the  diaphysis  is  in 
decided  pronation.  The  epiphysis  being  in  very  close  connection 
with  the  ulna,  the  former  is  slightly  pushed  towards  the  ulna  if 
the  ligamentous  connection  between  the  radial  fragment  and  the 
ulna  remains  intact.  This  phenomenon  finds  its  conspicuous  clin- 
ical expression  in  the  lateral  prominence  of  the  lower  end  of  the 
ulna.  Fig.  156,  for  instance,  shows  a  combination  of  upward  and 
inward  displacement  of  the  lower  fragment,  followed  by  outward 
bending  of  the  ulna. 

Wherever  displacement  demands  reposition  the  assistance  of 


222 


THE    RONTGEN    RAYS 


one  or  two  persons  is  desirable,  who  should  make  counter-exten- 
sion while  the  surgeon  replaces  the  displaced  fragment.  After 
the  exact  situation  of  the  fragments  is  ascertained  by  the  fluoro- 
seope,  the  surgeon  knows  at  once  how  to  replace  it  in  its  former 
and  normal  position.  This  is  done  by  making  manipulations, 
either  in  the  way  of  pressing  sideward  and  turning  the  fragment, 
or  by  putting  the  wrist  at  a  proper  angle,  and  thus  correcting  the 
abnormal  direction.     It  is  needless  to  say  that  upward  displace- 


PiG.     157. 


-Oblique    Intra-articular    Fracture,   Associated   with   Spiral- 
shaped  Fracture  of  Lower  End  of  Ulna. 


ment  requires  pressure  from  above  downward;  outward  displace- 
ment, pressure  from  within;  and  inward  displacement,  pressure 
from  without. 

The  oblique  triangular  type  generally  requires  downward  and 
inward  pressure.  In  Eig.  157,  however,  which  shows  this  triangu- 
lar type  associated  with  spiral  fracture  of  the  ulna,  the  triangular 
fragment  is  turned  upward  and  inward,  so  that  downward  and 
outward  pressure  is  required  for  reduction. 

The  author  grasps  the  hand  of  the  patient  as  in  a  firm  hand- 
shake by  the  left  hand,  while  the  patient's  thumb  is  held  by  his 
right  hand,  so  that  his  thumb  presses  the  fragment  downward  while 
his  index-finger  presses  it  inward  at  the  same  time.     If  the  direc- 


•SHOULDER    AND    UPPER    EXTREMITY  223 

tion  of  the  displacement  is  towards  the  ulna,  he  grasps  the  pa- 
tient's hand,  including  the  thumb,  with  his  own  right  hand,  and 
pushes  the  fragment  outward  with  his  lei'1  thumb  while  he  supports 
the  flexor  aspect  with  the  rest  of  his  hand.  During  these  manipu- 
lations counter-extension  must  be  exerted  at  the  lower  end  of  the 
arm.  If  it  is  impossible  to  reduce  the  fragment  in  this  manner, 
anaesthesia  must  be  employed.  This  manoeuvre  is  sometimes  facil- 
itated by  placing  a  book  or  a  piece  of  wood  underneath  the  ulna 
at  the  edge  of  a  table. 

Reposition  of  the  fragments  in  fractures  of  this  type  seldom 
fails  since  the  Rontgen  rays  became  such  a  reliable  guide.  Even 
in  impacted  fractures  the  interlocked  fragments  can  be  disen- 
tangled. 

If  there  is  a  simultaneous  injury  of  the  lower  end  of  the  ulna 
showing  displacement,  special  care  must  be  taken  to  press  the  frag- 
ment into  its  normal  place. 

In  multiple  fractures,  even  in  the  much  dreaded  Y-shaped 
variety,  the  articular  arch  of  the  radius  may  sometimes  be  restored 
by  repeated  efforts  of  reposition,  controlled  and  corrected  by  the 
Rontgen  rays. 

After  reposition  is  accomplished  a  fixed  dressing  must  he  em- 
ployed for  the  purpose  of  retaining  the  fragments  in  their  proper 
positions.  This  is  not  always  easy.  The  author  finds  that  no 
dressing  accomplishes  the  purpose  of  retaining  the  fragments  bet- 
ter than  plaster  of  Paris,  since  it  adapts  itself  to  the  contours  of 
the  wrist  in  any  desired  shape  or  direction,  and  can  be  adapted 
to  the  individuality  of  each  case. 

Before  the  Rontgen  era  the  fear  of  ischasmia  and  gangrene 
prevented  the  author  from  using  it  immediately  after  the  injury. 
Now  that  the  premises  of  ischgemia  are  known  to  be  wanting  as 
soon  as  the  pressure  of  displaced  fragments  is  removed,  such  fear 
is  uncalled  for.  So,  while  in  former  years  the  author  applied 
splints  first  and  resorted  to  the  plaster-of-Paris  dressing  four  to 
seven  days  afterward,  he  now  applies  the  plaster  dressing  imme- 
diately after  reduction,  resorting  to  the  splint  treatment  a  week 
or  two  later,  as  the  case  may  require.  If  the  protruding  fragment 
is  not  reduced,  gangrene  of  the  overlying  soft  tissues  may  be  pro- 
duced by  any  kind  of  dressing.  In  the  Journal  of  the  American 
Medical  Association,  November,  1902,  two  illustrations  showing 
extensive  gangrene  at  the  dorsum  as  well  as  on  the  palm,  which 


224 


THE    ROtfTGEST    RAYS 


was  caused  by  well-padded  splints,  were  presented.  TSTo  effort  at 
reduction  had  been  made.  Such  results  are  of  grave  consequence 
for  the  patient  as  well  as  for  the  surgeon. 

If  the  direction  of  the   displacement  is   slightly  upward,   or 
upward  and  outward  (Fig.  158),  a  plaster-of-Paris  dressing  em- 


Pig.  158. — Outward  Displacement  in  Fracture  of  the  Lower   End  of  the 
Radius,  in  a  Woman  of  Sixty  Years — Four  Days  after  the  Injury. 

bracing  the  thumb  (the  direction  of  the  thumb  influences  that  of 
the  fragment  to  a  great  extent)  is  applied  (Fig.  159).  The  hand 
is  moderately  flexed  at  the  same  time.  If  gentle  pressure  with  the 
index-finger  does  not  suffice  to  keep  the  fragment  down,  it  must  be 
pressed  down  by  a  signet  around  which  the  bandages  are  wound. 
After  the  splint  is  fastened  with  a  bandage,  the  fluoroscope  shows 
whether  the  fragment  is  in  a  desirable  position.  A  dorsopalmar 
as  well  as  a  lateral  examination  must  be  made,  because  an  antero- 
posterior view  only  shows  whether  there  is  a^r  upward  displace- 
ment left. 

If  the  fluoroscope  shows  imperfect  adaptation,  the  bandage 
must  be  removed  and  reposition  done  over  again.  Under  such  cir- 
cumstances the  fragment  may  better  be  retained  if  the  thumb  is 
pulled  in  an  outward  direction  while  the  hand  is  shifted  to  the 


SHOULDER  AND  UPPER  EXTREMITY    225 

opposite  side.  A  plaster-of-Paris  dressing,  applied  in  this  posi- 
tion, resembles  the  old  pistol  splint  of  Nelaton.  Of  course  the 
outward  bending  can  be  increased  ad  libitum.  A  surgeon  must  not 
lose  patience  if  his  efforts  fail  several  times.  By  the  lluoroscopic 
guidance  he  will  at  last  surely  find  the  proper  angle,  or  in  other 
words,  the  most  suitable  position  and  shape  of  the  dressing  or 
splint  for  his  individual  case.  A  recognised  mistake  often  suggests 
the  best  mode  of  correction. 

If  the  displaced  fragment  is  directed  towards  the  ulna,  in 
which  case  there  is  generally  an  outward  bending  of  the  ulna 
present,  immobilization  is  kept  up  best  by  turning  the  hand  in- 
ward (compare  Fig.  156).  After  a  week  the  dressing  must  be 
removed,  and  if  the  oedema  has  disappeared,  a  plaster-of-Paris 
splint,  moulded  after  the  same  principles,  may  be  substituted, 
which  can  be  taken  off  temporarily,  so  that  massage  treatment  may 
be  employed  if  necessary.  The  essential  part  of  these  splints  is 
the  encircling  of  the  thumb,  which  guarantees  absolute  immobil- 
ization. 

In  the  multiple  T-shaped  or  Y-shaped  variety  there  are  gen- 
erally two  diverging  fragments,  one  being  shifted  towards  the 


^  •*   ■■  ■  - 


Fig.    159. — Thumb   Splint— Hand    Slightly    Abducted — for    Fracture   fol- 
lowed by  Displacement. 


ulna  and  the  other  outwardly.  By  pressing  these  fragments 
asunder,  so  to  say,  the  diaphysis  is  made  to  push  itself  forward 
so  that  it  touches  the  scaphoid  bone,  the  arm  consequently  being 
shortened.  Here  the  circular  plaster-of-Paris  dressing  in  abduc- 
1G 


226  THE    RONTGEN    RAYS 

tion  is  indicated.  After  that  fragment,  which  is  outwardly  dis- 
placed, is  pressed  forward,  a  pad  of  adhesive  plaster  is  placed  above 
it.  The  fragment  which  is  displaced  towards  the  ulna  must  be 
shifted  in  the  direction  of  the  radius.  To  prevent  slipping  back 
a  rubber  drainage-tube  is  placed  between  it  and  the  ulna  at  the 
dorsal  aspect.  By  gentle  pressure  it  is  squeezed  down  into  the 
interosseous  space,  and  kept  in  situ  by  strips  of  narrow  adhesive 
plaster,  which  do  not  entirely  surround  the  arm. 

Since  this  type  is  intra-articular,  it  is  understood  that  there  is 
always  a  well-marked  extravasation  which  may  even  extend  over 
the  sheaths  of  the  tendons,  so  that  palpation  is  rendered  difficult. 
There  massage  is  best  employed  to  remove  the  extravasation. 
Naturally,  its  presence  renders  a  detailed  diagnosis  impossible 
except  by  the  rays. 

Among  all  the  different  varieties  of  fracture  of  the  small  end 
of  the  radius  these  intra-articular  injuries  are  most  serious.  Only 
continuous  control  by  the  aid  of  the  Rontgen  rays  of  the  proper 
position  of  the  fragments,  together  with  repeated  correction,  will 
give  a  fair  result. 

Fig.  15  shows  a  multiple  fracture  followed  by  slight  displace- 
ment of  the  lower  fragments.  Especially  that  fragment  which 
mainly  consists  of  the  styloid  process  of  the  radius  is  shifted  down- 
ward, thus  destroying  the  symmetry  of  the  wrist-arch.  It  is  very 
difficult  and  often  impossible  to  reduce  a  lower  fragment  of  this 
character  properly ;  still  much  can  be  done  by  being  able  to  locate 
it  exactly  on  the  basis  of  skiagraphic  knowledge.  In  this  case, 
which  concerned  a  man  of  fifty-five  years,  the  result  was  nearly 
perfect.  Being  of  the  intra-articular  type,  the  injury  was  followed 
by  the  formation  of  adhesions,  which  were  destroyed  during  after- 
treatment. 

In  the  case  of  considerable  comminution,  a  perfect  restitutio  in 
integrum  cannot  be  promised.  A  skiagraph  taken  at  the  earliest 
possible  moment  is  then  a  valuable  document  for  the  surgeon, 
since  it  proves  the  great  difficulty  of  perfect  reposition  of  the 
splinters. 

In  the  case  of  a  woman  of  twenty-five  years  the  lower  fragment 
was  turned  towards  the  ulna  and  also  around  its  axis  (see  Medical 
News,  September  11,  1903).  It  goes  without  saying  that  this 
extraordinary  degree  of  displacement  showed  considerable  deform- 
ity.    Reposition  was  accomplished  without  anaesthesia,  the  wrist 


SHOULDER    AND    CJPPER    EXTREMITY  227 

being  immobilized  in  superabduction.  A  skiagraph,  taken 
through  the  plaster-of -Paris  dressing,  showed  thai  the  abduction 
was  overdone,  therefore  another  dressing  was  applied  in  moderate 
abduction.  This  position  showed  the  fragments  in  better  coapta- 
tion, but  there  was  a  tendency  of  the  ulnar  side  of  the  fragment 
to  project  upward,  partially  filling  up  the  interosseous  space. 
Elastic  pressure,  recommended  by  the  author  in  the  treatment  of 
metacarpal  as  well  as  metatarsal  fracture,  also  proved  to  be  useful 
in  this  case.  A  small  piece  of  rubber  drainage-tube  (the  diameter 
of  a  large  pencil)  was  placed  alongside  the  interosseous  space  and 
fastened  there  with  a  small  strip  of  adhesive  plaster.  Now  the 
skiagraph  showed  perfect  adaptation.  That  it  had  spoken  truth- 
fully was  evident  from  the  absence  of  reaction,  which  should  have 
been  expected  in  view  of  the  enormous  degree  of  displacement  and 
by  the  speedy  and  blameless  recovery. 

There  is  no  doubt  that  good  results  can  be  obtained  by  other 
means  of  immobilization,  provided  they  are  preceded  by  proper 
reposition  controlled  by  the  Rontgen  light. 

The  author  confesses  freely  that  he  often  thought  that  he  had 
reduced  a  displaced  fragment  completely  because  palpation  seemed 
to  give  thorough  satisfaction.  But  he  sometimes  was  not  a  little 
surprised  that  the  Rontgen  plate  showed  him  most  impolitely  how 
ill  he  had  succeeded  in  his  alleged  reposition. 

The  main  principles  of  treatment  are  the  same  for  the  other 
types  of  fracture  of  the  lower  end  of  the  radius.  There  are,  how- 
ever, several  modifications  according  to  their  different  anatomy. 

If  in  cJiondro-epiphyseal  separation  no  sideward  displacement 
exists,  the  antero-posterior  exposure  shows  nothing  abnormal,  while 
a  side  view  may  disclose  considerable  upward  displacement,  as  is 
shown  by  Fig.  160,  for  instance,  the  anterior  view  of  which  re- 
vealed apparently  normal  relations.  Such  cases  are  best  treated  by 
gentle  downward  pressure  without  using  counter-extension  and  the 
application  of  a  plaster-of-Paris  dressing  in  extension.  If  a  lateral 
view  shows  any  sideward  displacement  under  the  dressing,  a  pad 
of  adhesive  plaster  is  attached  to  the  skin  above  the  lower  frag- 
ment and  the  dressing  reapplied. 

In  osteo-epipliyseal  separation,  where  the  fracture-line  is  not 
limited  to  the  epiphyseal  cartilage,  but  extends  to  the  diaphysis, 
a  greater  tendency  to  displacement  is  observed.  The  principles  of 
treatment  are  the  same  as  that  of  the  complete  fracture  described 


228  THE    RONTGEN   RAYS 

above,  since  the  tendencies  to  the  various  forms  of  displacement 
are  the  same. 

Fracture  of  the  lower  end  of  the  radius  associated  with  fracture 
of  the  styloid  process  of  the  ulna  is  rather  frequent  (see  Fig.  26). 
The  author's  own  statistics  show  that  the  styloid  process  is  in- 
volved in  26  per  cent  of  the  cases.  This  co-injury  was  discov- 
ered long  before  Rontgen  by  Nelaton  and  Velpeau,  and  studied 
especially  in  this  country  by  Pilcher,  Roberts,  Freeman,  Corson, 
Thomas,  Don,  Haughton,  and  Colton.     The  author  recommends  a 


Fig.  160. — Upward  Displacement  in  Chondko-epiphyseal  Separation. 

circular  plaster-of-Paris  dressing  in  moderate  adduction  for  this 
type.  Sometimes  it  is  possible  to  grasp  the  process  and  push  it 
back  into  its  proper  place.  This  is  easily  provided  if  the  process 
is  displaced  outward,  but  in  case  of  inward  displacement  reposi- 
tion is  much  more  difficult.  The  author  has  found  it  useful  to 
press  this  fragment  outward  by  pushing  the  dull  end  of  a  pencil 
between  the  process  and  the  radius,  and  keeping  it  there  until  the 
dressing  is  completed,  the  bandages  being  wound  around  the  pen- 
cil.   A  small  piece  of  rubber  tube  may  also  be  placed  there. 

A  small  amount  of  pressure  often  suffices  to  push  the  fragment 
into  position,  while  after  the  lapse  of  weeks  the  inversion  of  the 
process  may  cause  intense  pain  on  any  effort  of  bending  the  wrist, 
so  that  removal  by  chisel  may  have  to  be  considered. 


SHOULDER  AND  UPPER  EXTREMITY     229 

In  fractures  of  the  lower  end  of  the  radius  associated  with  dis- 
location of  the  ulna,  the  lower  radial  fragment  generally  rides 
on  the  diaphysis,  the  latter  protruding  at  the  flexor  aspect  and  the 
former  at  the  dorsum.  The  ulnar  end  then  overlaps  the  carpus. 
Only  a  considerable  degree  of  violence  can  produce  this  rare  injury. 
In  such  cases  the  arm  is  shortened  at  least  an  inch  (Fig.  162). 
Reduction  is  easier  than  retention  after  reduction.  Sometimes  an 
extension-splint  will  answer,  but  in  the  majority  of  cases  wiring 
of  the  radial  fragments  is  better  done  at  once,  and  the  patient 
should  be  thoroughly  informed  of  the  grave  nature  of  the  injury. 

Fig.  163  illustrates  the  condition  after  operation. 

Fracture  of  the  lower  end  of  the  radius  associated  with  fissure 
of  the  neck  of  the  ulna  is  treated  after  the  same  principles  as  the 
complete  fracture  of  the  lower  end  of  the  radius.  This  applies 
also  to  fracture  without  displacement.  But  if  there  be  displace- 
ment, generally  outward  bending  of  the  lower  fragment,  some- 
times in  spiral  shape,  as  in  Fig.  157,  a  plaster-of -Paris  splint  in 
moderate  adduction  is  applied  after  reposition.  A  pad  of  adhesive 
plaster  is  also  placed  at  the  outer  aspect  of  the  ulna.  Should 
there  be  any  inversion,  a  small  rubber-drain  must  be  pressed  in  the 
interosseous  space. 

Fig.  161  shows  a  case  of  this  type,  in  which  the  violence  in- 
flicted upon  the  radial  fragment  was  continued  upon  the  lower 
end  of  the  ulna,  causing  fracture. 

Another  co-injury,  the  transverse  fracture  of  the  scaphoid 
bone,  deserves  thorough  attention.  Fortunately,  as  a  rule,  but 
little  or  no  displacement  is  present,  but  the  character  of  the  injury 
being  intra-articular,  it  is  appreciated  that  there  is  considerable 
intra-articular  effusion,  which  is  largely  responsible  for  the  great 
tendency  to  adhesion  formation  in  these  cases.  The  treatment  is 
practically  the  same  as  that  for  the  fracture  described  above,  with 
the  difference  that  motion  must  begin  early.  It  is  therefore  ad- 
visable to  remove  the  circular  dressing  somewhat  earlier  than  in 
other  types  and  to  substitute  a  plaster-of-Paris  splint,  the  same 
shape.  This  splint  may  be  taken  off  temporarily  every  day  so  that 
gentle  massage  can  be  commenced. 

Fracture  of  little  bone  portions  (chips),  generally  of  the 
extra-articular  type,  are  often  confounded  with  contusion  or  dis- 
tortion. In  such  cases  massage  treatment  is  manifestly  inappro- 
priate; the  treatment  should  be  carried  on  after  the  principles  of 


230  THE    RONTGEN    RAYS 

the  treatment  of  fractures — viz.,  immobilization.  This  should  be 
kept  up  for  the  first  week  after  the  injury  at  least,  and  after  the 
little  fragments  are  redressed. 

Such  chips  are  sometimes  no  longer  than  the  head  of  a  pin, 
and  if  they  are  separated  from  the  dorsal  or  palmar  surface  of 
the  radius,  may  not  be  at  all  conspicuous  on  the  skiagraphic  plate, 
while  a  lateral  exposure  will  show  them. 

If  the  massage  treatment  so  commendable  in  contusion  is  used 
in  these  cases,  it  is  not  surprising  that  the  patient  becomes  rebel- 
lious, it  is  indeed  not  at  all  indifferent  whether  a  simple  bloody 
effusion  or  keen-edged  bone-fragments  are  kneaded. 

It  is  deplorable  that  up  to  the  present  the  question  of  correct- 
ing the  deformities  must  still  be  considered.     Two  or  three  weeks 


taflfl 


Fig.   161. — Fracture  of   Lower  End   of  Radius   associated  with  Fracture 
of  Ulnar  End,  in  a  Woman  of  Sixty-eight  Years. 

after  the  injury  correction  is  possible  by  simple  refracture.  After 
the  lapse  of  four  to  five  weeks  the  only  remedy  consists  in  osteot- 
omy in  the  fracture-line.    Aged  persons  suffering  from  deformity 


SHOULDEE    AND    [JPPER    EXTREMITY  231 

of  this  kind  are  exempted  (sec  Fig.  L61).  If  they  suffer  while 
motion  is  made,  immobilization  is  best  kept  up  with  a  moss  brace- 
let until  ankylosis  of  the  wrist  has  taken  place.    Sometimes  a  small 


Fig.  162.—  Fracture  of  Lower  End  of  Radius,  associated  with  Dislocation 

of  Ulna. 

wedge  must  be  exseeted  from  the  ulna  in  order  to  permit  of  per- 
fect reposition. 

Such  operations  must  be  performed  under  the  strictest  aseptic 
precautions,  tearing  of  the  wound  edges  must  be  avoided,  and  the 
wound  itself  should  come  in  contact  with  the  hands  of  the  surgeon 
as  little  as  possible,  since  all  the  work  can  be  done  with  well-ster- 
ilized instruments.  If  the  Eontgen  rays  show  that  the  efforts  of 
early  reposition  were  unsuccessful,  although  anaesthesia  was  em- 
ployed, it  is  much  wiser  to  expose  the  fragments  by  open  incision 
at  once  than  to  wait  until  the  tissues  around  the  area  of  faulty 
union  degenerate.  As  soon  as  the  bloody  effusion  is  absorbed  the 
operation  should  be  performed.  Isolated  bone  splinters,  the  peri- 
osteum of  which  shows  no  more  coherence,  must  be  removed.  If 
the  fragments  cannot  be  brought  into  apposition  by  simple  reduc- 
tion, then  the  ends  must  be  trimmed  properly  with  wire,  saw,  or 
chisel,  and  either  indentated  or  wired. 


232  THE    EONTGEN    EAYS 

Fig.  162  shows  the  fracture  of  the  lower  end  of  the  radius, 
followed  by  overlapping  of  the  lower  fragment  and  associated 
with  palmar  dislocation  of  the  ulna.  The  protrusion  at  the  flexor 
aspect  corresponds  to  the  projection  of  the  diaphyseal  end,  while 
the  dorsal  prominence  indicated  the  riding  of  the  epiphysis.  The 
skiagraph  also  shows  the  forward  dislocation  of  the  ulna,  the  extent 
of  which  is  proportioned  to  the  amount  of  yielding  on  the  part  of 
the  epiphyseal  fragments.     Consequently  the  arm  was  shortened. 


Fig.  163. — Case  Illustrated  by  Fig.  164,  after  Operation,  the  Trimmed 
Radial  Fragments  being  in  Apposition  after  Correction  of  the  Ulnar 
Portion.     (Taken  through  the  plaster-of -Paris  dressing.) 

Skiagraph  (Fig.  163),  taken  through  the  plaster-of-Paris  dressing 
two  days  after  osteotomy,  shows  the  trimmed  radial  fragments  in 
apposition  and  the  dislocated  portion  of  the  ulna  resected.  Con- 
sequently the  extremity  became  an  inch  shorter. 

As  to  tuberculosis  of  the  wrist,  the  carpus,  metacarpus,  and 
phalanges,  frequent  in  children,  which  can  be  well  studied  and 
treated  under  the  guidance  of  the  rays,  the  reader  is  referred  to 
their  respective  sections. 

HAND 

The  hand  is  the  easiest  object  for  Eontgen  examination.  It 
may  be  fluoroscoped  in  the  dorsal  as  well  as  in  the  palmar  position, 


SHOULDER  AND  UPPER  EXTREMITY     233 

the  best  skiagraphic  results  being  obtained  if  the  dorsum  rests  on 
the  plate. 

Especially  the  interpretation  of  the  small  carpal  bones  is  some- 
times difficult,  and  no  judgment  should  be  passed  without  having 
them  exposed  in  at  least  two  different  projection  planes — that  is, 
preferably  in  the  postero-anterior  and  in  the  lateral  position.  In 
children  the  hand  is  fastened  to  the  plate  with  a  gauze  bandage,  a 
soft  tube  being  employed.  In  very  lively  children  short  exposures 
must  be  taken,  the  hand  being  held  down  firmly  by  an  assistant. 
A  fairly  good  skiagraph  may  be  obtained  in  one  or  two  seconds, 
a  tube  of  medium  hardness  then  being  needed. 

The  dorsal  position  is  uncomfortable,  therefore  support  with 
sand-bags  is  indispensable.  Children  may  assume  the  recumbent 
position  if  a  dorsal  exposure  is  chosen.  The  hand  of  an  adult  can 
be  taken  in  fifteen  seconds.  Most  skiagraphs  of  the  hand  are 
over-exposed,  the  contrasts  then  not  being  apparent.  A  good  skia- 
graph of  the  hand  shows  the  soft  parts  to  a  great  extent,  espe- 
cially the  muscles  from  which  even  the  finger-nails  must  be  differ- 
entiated. Diaphragms  are  not  required  in  the  examination  of  the 
hand. 

Fracture  of  the  carpal  bones  received  consideration  in  connec- 
tion with  the  description  of  fracture  of  the  lower  end  of  the 
radius.    The  isolated  fractures  of  the  carpus  are  rare. 

Fig.  164  illustrates  the  fracture  of  the  scaphoid  bone  in  a 
woman  of  sixty  years,  caused  by  a  fall  on  the  outstretched  hand. 
In  this  case  a  contusion  of  the  wrist  must  have  taken  place,  the 
force  inflicted  upon  the  very  strong  radial  end  having  been  trans- 
ferred upon  the  less  resisting  scaphoid  bone. 

As  to  fractures  of  other  carpal  bones  (os  lunatum),  the  reader 
is  referred  to  Annals  of  Surgery,  August,  1901. 

The  fractures  of  the  carpus  are  undoubtedly  more  frequent 
than  is  generally  assumed.  But  they  were  not  recognised  for- 
merly. 

Metacarpus. — The  Rontgen  rays  have  also  shaken  the  old  dic- 
tum of  the  rarity  of  fracture  of  the  metacarpal  bones.  There  can 
now  be  no  more  doubt  that  a  large  number  of  alleged  dislocations 
and  contusions  of  the  metacarpus  were,  in  fact,  either  complete 
fractures  in  adults  or  separations  of  the  epiphyses  in  children. 

In  most  cases,  displacement  of  the  fragments  being  absent, 
and  the  other  metacarpal  bones  serving  to  a  certain  extent  as 


234 


THE    RONTGEN    RAYS 


splints,  it  is  natural  that  the  results  in  these  cases  were  nearly 
always  good,  no  matter  what  treatment  was  employed ;  the  post 
hoc,  ergo  propter  hoc  heing  sufficient  evidence  for  the  superficial 


Fig.  164.— Isolated  Fkactuke  of  Scapiioid  Bone. 


observer.  If,  however,  he  had  used  the  Bontgen  rays,  he  would 
have  been  not  a  little  surprised  to  find,  in  such  a  case,  the  evi- 
dence of  a  fracture;  while  at  the  same  time  he  could  congratulate 
himself  that  in  spite  of  his  treatment  for  simple  contusion  the 
result  was  so  perfect. 

In  the  event  of  displacement  the  result  would  be  somewhat 
different.  If  the  displacement  is  in  the  dorsal  direction,  it  is  not 
only  easily  recognised,  but  also  reduced  and  kept  in  place  without 
difficulty  by  coaptation  splints.  But  if  the  displacement,  as  it 
often  occurs,  is  sideways,  the  result  may  be  very  unsatisfactory, 
the  remaining  deformity  and  disturbance  of  function  being  consid- 
erable. If  a  common  labourer  is  concerned,  but  little  inconven- 
ience may  be  caused  by  it ;  but  if  a  person  whose  hands  must  do 
delicate  work,  like  a  musician,  watchmaker,  cabinetmaker,  or,  last 


SHOULDER    AM)    UPPER    EXTREMITY 


235 


but  not  least,  a  physician,  is  the  victim,  badly  united  metacarpal 
fragments  of  the  right  hand  may  seriously  interfere  with  his  pro- 
fessional work. 

Reduction  of  the  displaced  fragments  never  offers  any  insur- 
mountable obstacles;  but  to  hold  them  in  place  is  a  far  more  com- 
plicated task,  and  the  recurrence  of  the  displacement  under  the 
usual  immobilizing  methods  shows  their  insufficiency  in  the  end. 

The  question  now  is,  What  is  to  be  our  guide  in  estimating 
the  value  of  a  given  immobilizing  method  before  consolidation 
has  taken  place?  In  former  years  we  used  to  judge  the  value  of 
one  or  another  method  by  the 
final  result.  But  now,  just  as 
we  estimate  the  value  of  a 
germ-destroying  method  first 
of  all  by  bacteriological  ex- 
periment, so  we  are  able  to 
judge  by  irradiation  at  the 
very  beginning.  If  the  im- 
mobilizing dressing  is  perfect, 
the  formerly  displaced  frag- 
ments must  be  found  in  exact 
apposition  when  skiagraphed 
through  the  dressing. 

Various  experiments  showed 
the  author  that  the  metacar- 
pal fragments  are  invariably 
held  in  place  by  elastic  press- 
ure. For  this  purpose  two 
rubber  drainage-tubes  of  mod- 
erate size  are  chosen,  which 
are  lightly  pressed  into  the 
adjoining  interosseous  spaces, 
so  that  they  fill  them  up  to  a 

certain  extent.  They  are  kept  in  situ  by  adhesive-plaster  strips 
(Fig.  165).  Thus  the  recurrence  of  the  displacement  is  prohibited, 
The  whole  is  surrounded  then  by  a  moss-splint,  a  material  which, 
after  being  dipped  in  cold  water,  adapts  itself  to  the  contours  of 
the  hand  like  a  plaster-of-Paris  splint,  over  which  it  possesses  the 
great  advantages  of  being  absorbent  and  much  lighter. 

In  the  case  of  a  young  man,  who  sustained  fracture  of  the 


Fig.   165. — Drainage-tube    Splints  eor 
Metacarpal  Fracture. 


236 


THE    RONTGEN    RAYS 


fourth  metacarpal  bone  in  its  middle  as  a  result  of  direct  violence, 
considerable  lateral  displacement  was  produced  (Fig.  166).  Repo- 
sition was  easily  accomplished  and  the  fracture  area  was  carefully 


Fig.   166. 


-FRACTURE   OF     FOURTH    METACARPAL    BONE,    CAUSING     SIDEWARD     DIS- 
PLACEMENT.     (Compare  Fig.  165.) 


surrounded  by  narrow  pads,  which  were  supported  by  adhesive 
plaster.    A  long  palmar  extension  splint  was  then  applied. 

There  was  no  swelling  of  the  fingers  nor  any  sign  of  discom- 
fort. But  when  examining  the  metacarpus  two  weeks  later  with  a 
view  to  leaving  the  splints  off,  the  author  found  that  the  fragments 
had  slipped  by  each  other  again.  He  then  seriously  considered 
other  means  of  immobilization.  After  filling  up  the  interosseous 
grooves  between  the  fourth  metacarpal  bone  and  the  little  finger 
on  one  side  and  the  third  one  on  the  other  with  two  rubber  drain- 
age-tubes, the  author  took  a  skiagraph,  which  showed  the  frag- 
ments in  ideal  apposition.  Shortly  afterward  he  removed  the  rub- 
ber tubes,  and  then  the  displacement  recurred  at  once.  From  this 
we  also  learn  that  it  is  unwise  to  rely  upon  the  old  dictum  that 
metacarpal  fractures  show  perfect  consolidation  after  three  weeks. 
We  should  consult  the  Rontgen  rays  before  satisfying  ourselves  as 
to  the  question  of  impeccable  union.  (As  to  further  details,  see 
New  York  Medical  Journal,  August  1,  1900.) 


SHOULDER    AND    UPPER    EXTKK.MITV 


237 


Fig.  167  illustrates  the  fracture  of  the  second  metacarpus  in 
a  man  of  twenty-three  years.  There  was  but  a  slight  degree  of 
sideward  displacement,  still  the  sharp  point  of  the  lower  fragment 
projected  to  the  soft  tissues,  causing  much  irritation.  As  soon 
as  inward  and  downward  pressure  was  exercised  the  pain  ceased. 

Fig.  168  shows  fractures  of  the  fifth  metacarpus.  There  is 
good  apposition,  but  much  ensheathing  callus,  which  caused  adhe- 
sions to  the  soft  tissues,  so  that  the  function  was  much  disturbed. 
Thus  the  patient,  a  young  professional  violinist,  may  be  prevented 
from  following  the  footsteps  of  Paganini. 

Immobilization  had  been  attempted  in  this  case  by  a  short 
phalangeal  splint.  While  reposition  as  well  as  immobilization  of 
the  fifth  metacarpal  bone  is  easier  than  that  of  any  of  its  fellows, 
the  fragments  cannot  be  held  in  situ  by  simple  pressure  from  with- 


Fig.  167. — Fracture  of  the  Second  Metacarpal  Bone. 


out,  a  rubber  drainage-splint  should  therefore  be  placed  in  the 
space  between  them  and  the  fourth  metacarpal  bone. 

Fig.  169  illustrates  the  deformed  fracture  of  the  second  meta- 
carpal bone  in  a  musician  of  forty  years.  The  fracture  was  sus- 
tained fifteen  years  before  the  skiagraph  was  taken,  and  until  then 
a  dislocation  had  been  assumed.  The  career  of  the  patient  was 
greatly  impaired,  as  he  had  to  descend  from  his  pedestal  as  a  mas- 


238 


THE    KONTGEN    RAYS 


ter  of  the  bassoon  to  the  drum.  If  the  rays  had  been  discov- 
ered at  the  time  of  the  injury  this  would  probably  have  been 
averted.  An  effort  was  made  by  the  author  to  reduce  the  frag- 
ment after  mobilizing  it  with  the  chisel,  but  this  proved  to  be  im- 
practicable, therefore  the  fragment  was  removed.  Thus  an  im- 
pediment for  free  motion  was  eliminated.  As  far  as  the  short 
observation  of  the  case  shows  the  result  is  perfect,  so  that  the 
patient  may  still  be  able  to  perform  higher  graded  work. 

Phalanges. — While  the  signs  of  fracture  of  the  phalanges  are 
well  marked,  there  are  cases  in  which  differentiation  from  dis- 
location or  inflammatory  processes  is  difficult.  The  Eontgen 
method,  of  course,  gives  the   most  precise  information.      Some- 


Fig.  168.— Fracture  in  the  Middle  of  the   Fifth  Metacarpal  Bone,  show- 
ing Ensheathing  Callus. 


times  a  fracture  is  recognised  by  palpation,  but  a  number  of  asso- 
ciated injuries  are  overlooked.  The  skiagraph  gives  a  splendid 
general  view  in  such  an  instance,  calling  attention  to  points  which 
were  not  thought  of. 


SHOULDER    AND    UPPER    EXTREMITY  239 

In  treating  phalangeal  fractures  it  is  recommended  to  use  the 
rubber  drainage-splints  advised  by  the  author,  and  to  confine  the 
whole  hand.  This  may  be  done  by  a  palmar  splint  or  a  short 
plaster-of-Paris  dressing,  at  least  for  the  week  following  the  in- 


Fit;.  169. — Old  Displaced  Fkactukk  of  the  Second  Metacarpal  Bone. 

jury.  Then  a  short  wooden  phalangeal  splint  may  be  resorted  to. 
The  much-favoured  cardboard  splint  seems  to  be  useful,  but  is  not 
firm  enough,  as  is  shown  by  skiagraphy,  and  should  therefore  be 
discarded. 

Foreign  bodies  in  the  hand  are  easily  shown.  Especially 
needles  in  the  palm  often  come  under  the  observation  of  the  prac- 
titioner. 


CHAPTER    XII 


HAL  FORM  A  TIONS 


As  previously  mentioned,  the  great  scientific  and  practical 
value  of  the  Rontgen  rays  is  also  evident  in  the  study  of  congenital 
malformations.  Skiagraphy  of  the  extremities  especially  has  given 
more  valuable  information  than  dissection.  The  exact  anatomical 
diagnosis  that  it  enables  us  to  make  informs  us  whether  surgical 
interference  in  a  case  of  malformation  is  possible,  and  if  so,  out- 
lines clearly  our  modus  operandi  beforehand.  The  ingenious  oper- 
ations of  Bardenheuer  (division  of  the  ulna  for  carpal  implanta- 
tion) and  of  von  Eiselsberg  (transplantation  of  the  toe),  and  the 


Fig.  170. — Syndactylism  of  Third,  Fourth,  and  Fifth  Finger  in  a  Child  of 

Eight  Months. 


works    of    Kirmisson,    Vulpius,    Middleton,    Pagenstecher,    von 
Bardeleben,  Joachimsthal,  Schede,  Lambert,  and  Grrunmach  fur- 
nish most  brilliant  testimony  to  our  progress  in  this  direction. 
240 


MALFORMATIONS  241 

Fortunately  the  most  frequent  abnormality  ie  the  one  that  can 
be  easily  remedied — namely,  polydactylism.  If  there  is  but  a  rudi- 
mentary finger  attached  loosely  by  a  pedicle  and  containing  no 


Fig.  171. — Metatarsal  Synostosis  in  a  Baby. 

phalanges  at  all,  removal  is  very  simple.  But  when,  as  is  the  rule, 
there  is  a  true  supernumerary  digit  articulating  with  another 
phalanx  or  the  head  or  side  of  a  metacarpal  bone,  the  site  of  exar- 
ticulation  must  be  well  known  before  the  operation.  Otherwise 
the  better  developed  phalanx  may  be  sacrificed. 

Syndactylism,  while  not  so  frequent  as  polydactylism,  also 
represents  a  large  group  of  cases  of  malformation  of  the  upper 
extremity,  and  is  likewise  amenable  to  operative  interference. 

In  a  case  of  syndactylism  in  a  boy  of  eight  months,  the  second, 
third,  and  fourth  digits  appeared  to  be  fused  together,  each  one 
of  them,  however,  possessing  its  own  nail.  The  skiagraph  (Fig. 
170)  showed  fusion  of  the  first  and  second  phalanges  of  the  third 
and  fourth  digits,  while  their  third  phalanges  were  free.  The  little 
finger  was  more  developed  than  the  slightly  deformed  thumb.  The 
carpus  was  not  yet  ossified,  and  therefore  showed  no  shade.  Under 
the  guidance  of  the  Eontgen  rays  it  was  easy  to  divide  the  pha- 
17 


242 


THE    RONTGEN    EAYS 


langes.  The  middle  finger  was  protected  easily  by  a  large  longi- 
tudinal flap  from  the  dorsal  surface  of  the  hand.  The  other  two 
fingers  were  covered  with  their  integument,  longitudinal  flaps  being 

formed  from  the  palmar  sur- 
face for  the  second  finger, 
and  another  one  from  the 
dorsal  side  of  the  fourth. 
The  final  result  was  good. 

Syndactylism  is  some- 
times found  simultaneously 
in  both  extremities.  Fig. 
171  illustrates  metatarsal 
synostosis  in  a  baby. 

Congenital  deficiencies 
are  naturally  much  less 
amenable  to  correction.  But 
that  surgery  is  not  without 
resources  even  in  desperate 
cases  of  this  kind  is  made 
evident  by  the  transplanta- 
tion of  a  toe  to  the  hand, 
successfully  undertaken  by 
von  Eiselsberg. 

Fig.  172  illustrates  the 
case  of  a  child  of  eight 
months  whose  second,  third, 
and  fourth  fingers,  as  well  as 
his  second,  third,  and  fourth 
toes  were  webbed.  Palpa- 
tion did  not  show  whether 
there  was  synostosis  or  not. 
As  the  bones  were  very  near  together,  the  impression  prevailed  that 
there  was.  But  the  skiagraph  gave  the  information  that  the  pha- 
langes were  well  developed  individually,  and  that  therefore  they 
did  not  need  to  form  the  object  of  an  operation,  the  skin  being  the 
only  part  to  be  considered.  A  plastic  operation  performed  then 
showed  that  the  phalanges  could  be  separated  from  each  other 
without  dissection. 

The  toes  were  left  alone. 

In  braclnjdaclylism,  combined  with  ectrodactylism,  the  Ront- 


Fig.  172. — Webbed  Fingers  and  Toes. 


MALFORMATION'S 


243 


gen  rays  have  also  proved  to  be  of  great  value.  In  the  case  of  a 
boy  of  three  months  there  were  five  rudimentary  fingers.  The 
skiagraph  showed  the  presence  of  one  phalanx  of  the  thumb  and 
of  two  phalanges  of  each  of  the  other  fingers. 

Under  the  guidance  of  the  Rontgen  rays  a  flap  operation  was 
performed,  on  the  principles  set  forth  in  the  case  described  above, 
between  the  first  and  second  finger  rudiment.  Thus  a  fairly  good 
thumb  was  created.  The  case,  however,  offered  two  more  points  of 
interest.  In  the  first  place  there  was  a  congenital  fracture  of  the 
ulna  and  radius  at  their  lower  third,  as  was  also  illustrated  by 
skiagraphy.  The  forearm  could  easily  he  bent  at  the  seat  of  the 
fracture.  After  wir- 
ing the  fragments 
union  became  perfect. 
(See  Congenital  Mal- 
formations of  the  Up- 
per Extremity,  New 
York  Medical  Jour- 
nal, June  29,  1901.) 

There  was,  fur- 
thermore, congenital 
constriction  at  the  re- 
gion of  the  surgical 
neck  of  the  humerus, 
where  a  deep  furrow 
encircled  the  whole 
circumference  of  the 
arm.  Palpation  was 
unable  to  detect  any 
soft  tissues  between 
the  integument  and 
the  bone.  An  explor- 
atory incision  re- 
vealed the  presence  of  fragments  of  the  biceps,  triceps,  and  del- 
toid muscles.  Their  edges  were  refreshed  and  united  with  catgut. 
For  relaxation  two  deep  wire  sutures  were  introduced  from  with- 
out.   The  result  was  fair. 

It  may  be  added  that  the  otherwise  well-developed  hand  showed 
a  moderately  deep  constricting  furrow  near  the  metacarpophalan- 
geal junction  of  the  middle  finger,  which  did  not  seem  to  demand 


Fig.   173. — Congenital  Club-hand,  and  Absence 
of  Radius  and  Ulna. 


244  THE    KONTGEN    KAYS 

surgical   interference,   since  the   skiagraph   showed   its   integrity 
otherwise. 

It  seems  that  this  special  branch  of  surgery  does  not  receive 
the  attention  it  merits.    Considering  that  in  the  lower  animals,  as 


Fig.  174. — Congenital  Dislocation  of  the  Wrist. 


246 


THE    ROXTGEN    RAYS 


long  as  in  the  embry- 
onic stage,  regenera- 
tion of  large  portions 
of  the  head  and  trunk 
are  possible,  it  should 
be  expected  that  the 
new-born  child — in  a 
smaller  proportion  of 
course  —  also  offers 
more  chances  for  re- 
generation than  the 
adult.  If  the  germi- 
nal layer  is  only  pres- 
ent, further  develop- 
ment of  the  tissues 
can  be  looked  for.  If 
a  part  of  a  phalanx  is  properly  severed,  its  individualization  is  a 


Fig.  176. — Congenital  Absence  of  Nasal  Bones. 


Fig.  177.— Skiagraph  of  Case  of  Rudimentary  Ear,  Illustrated  by  Fig.  178. 


MALFORMATIONS 


247 


matter  of  great  probability,  provided  the  bridge  remaining  has 
preserved  sufficient  vascularity  for  nutrition,  that  there  is  no  over- 
extension of  the  flap,  and  that  the  most  minute  aseptic  precautions 
are  taken. 

In  a  case  of  congenital  club-hand  associated  with  absence  of 
the  radius  and  ulna,  only  three  fingers  and  three  metacarpal  bones 
were  present,  as  became  evi- 
dent by  skiagraphic  examina- 
tion (Fig.  175). 

The  left  arm  of  the  boy 
was  normal  excepting  the 
thumb,  which  was  partially 
eetrodactylic.  An  attempt  was 
made  to  improve  this  deplo- 
rable condition  by  creating 
a  thumb  after  the  principle 
carried  out  in  the  case  just 
described.  For  this  purpose 
a  dorsal  incision  was  made 
down  to  the  first  metacarpal 
bone,  which  was  divided  lon- 
gitudinally, thus  making  a 
kind     of     bifurcation.       The 

phalangeal  end  was  severed  Pl*  178.  -  Rudimentary  Ear  in  a 
1  °  Child  of   Three   Months.      (Compare 

entirely,   but   the   carpal   end, 

after  being  fractured  longi- 
tudinally, was  left  in  slight  connection  with  the  metacarpal  bone. 
Thus  a  new  bone  was  obtained  that  was  surrounded  by  dorsal  as 
well  as  palmar  flaps.  There  was  little  trouble  during  the  after- 
treatment. 

Fig.  174  illustrates  congenital  dislocation  of  the  hand  of  a  man 
of  thirty  years.  There  is  considerable  atrophy  and  the  function 
is  very  much  disturbed. 

Most  malformations  of  the  foot  are  of  a  similar  nature,  and 
their  therapy  has  to  be  viewed  from  the  same  points  of  view. 

Fig.  175  illustrates  the  supernumerary  toes  in  a  boy  of  six 
months.  The  phalanges  of  the  fifth  toe  are  well  developed,  while 
the  supernumerary  appendix  shows  only  traces  of  osseous  tissue. 
It  was  natural  therefore  that  the  sixth  was  to  be  regarded  a  true 
supernumerary  digit;  therefore  it  was  removed.    • 


Child  of   Three   Months. 
Fig.  177.) 


248  THE    BONTGEN    EAYS 

In  the  Journal  of  the  American  Medical  Association,  October 
12,  1901,  a  series  of  cases  representing  congenital  malformations 
is  illustrated.  Among  them  the  case  of  a  boy  of  three  weeks  whose 
left  lower  extremity  was  normal,  while  the  right  one  showed  short- 
ening of  the  femur  to  the  extent  of  an  inch,  is  especially  note- 
worthy. There  was  no  muscular  atrophy.  Shortening  of  the 
healthy  femur  for  the  purpose  of  equalization  was  suggested.  In 
a  similar  case,  concerning  a  child  of  six  months,  the  shortening  of 
the  healthy  femur  was  successfully  performed  by  the  author. 
There  was  no  disturbance  of  development  observed,  the  time  of 
observations  being  two  years  now. 

Congenital  absence  of  the  nasal  bones  and  insufficient  develop- 
ment of  the  nasal  processes  of  the  superior  maxilla  was  observed 
in  a  boy  of  two  months  (Fig.  176).  The  patient  was  ill  nour- 
ished, and  the  family  history  was  negative. 

As  to  congenital  obliteration  of  the  auditory  canal,  see  Figs. 
177  and  178.     (Compare  page  65.) 


CHAPTER    XIII 
DISEASES  OF  THE  BONES  AND  JOINTS 

As  alluded  to  in  the  General  Part,  the  bones  give  the  human 
body  form,  erectness,  and  firmness,  the  latter  being  the  mosl  essen- 
tial feature  of  a  normal  bone.  The  firmness  of  the  bone  is  vouch- 
safed by  its  heavy,  hard,  and  dense  consistency,  which  is  pre-emi- 
nently based  upon  the  presence  of  calcium  phosphate.  The  per- 
centage of  this  salt  amounts  to  as  high  as  84.  There  is  also  a 
slight  admixture  of  magnesia  and  traces  of  calcium  chlorate  and 
fluorocalcium. 

It  is  the  density  of  these  inorganic  elements  which  prevents 
penetration  by  the  rays,  thus  producing  a  marked  shadow  in  con- 
trast to  the  more  translucent  organic  tisues  of  the  body. 

It  is  obvious  that  any  change  affecting  the  density  of  the  bone, 
in  other  words,  the  chemical  components,  must  show  on  skiagraphic 
examination.  And,  in  fact,  there  is  no  bone  affection  which  is  not 
characterized  by  more  or  less  marked  skiagraphic  features.  If  it 
is  considered  how  meagre  sometimes  the  information  gained  by 
inspection,  palpation,  probing  or  aspiration  is,  the  immense  im- 
portance of  a  method  which  gives  us  definite  information  by  a 
painless  procedure  will  be  realized. 

The  characteristic  points  of  differentiation  between  the  impor- 
tant osseous  diseases  were  outlined  by  the  author  in  his  essay  in  the 
Journal  of  the  American  Medical  Association,  June  3,  1901. 
In  general,  the  views  emphasized  there  were  corroborated  by  fur- 
ther observation. 

OSTEOMYELITIS 

While  it  is  not  difficult  to  diagnosticate  osteomyelitis  in  its  ad- 
vanced stage,  especially  after  the  cortex  as  well  as  the  periosteum 
have  participated  in  the  inflammatory  process,  the  initial  stage  can 
but  rarely  be  recognised  by  the  usual  methods. 

249 


250 


THE    RONTGEN    RAYS 


Usually  the  patient  complains  of  pain,  which  is  most  intense  at 
night,  in  one  of  the  large  bones.  Palpation  sometimes  reveals  a 
slight  thickening  of  the  affected  bone.    But  it  may  just  as  well  be 


Fig.  179.— Osteomyelitic  Focus  of  Humerus. 


absent.  A  preceding  trauma,  a  furuncle,  or  an  acute  infectious 
disease  (scarlet  or  typhoid  fever,  diphtheria,  or  measles)  often 
open  the  avenue  of  infection.  The  pain,  the  oedema,  the  fever, 
and  general  debility  are  sometimes  so  little  marked  that  differ- 
entiation becomes  difficult.  The  skiagraph  not  only  clears  this 
difficulty  of  diagnosticating  this  disease,  the  true  aetiology  of  which 
is  still  so  obscure,  but  also  furnishes  a  trustworthy  guide  for  the 
operative  technique.  Osteomyelitis  is  of  a  decidedly  infectious 
character,  generally  due  to  the  invasion  of  the  staphylococcus  into 
the    blood    circulation.      Fortunately,    the    staphylococcus    has    a 


DISEASES   OF   THE    BONES   AND   JOINTS        251 

tendency  of  inducing  the  formation  of  circumscribed  foci  in  the 
vascular  tissues  of  the  bones — viz.,  the  medulla. 

If  the  infection  is  due  to  the  typhoid  bacillus,  the  suppuration 
loses  its  acute  character,  an  abscess  generally  forming.  The  pre- 
dilection of  osteomyelitis  is  for  the  long  bones  of  young  individ- 
uals. It  is  self-evident  therefore  thai  the  early  recognition  of 
osteomyelitic  foci  renders  the  prognosis  of  their  evacuation  ex- 
tremely favourable. 

As  alluded  to  in  diseases  of  the  humerus  in  the  ease  of  a  lady 
of  twenty  years,  the  slow  onset  of  the  symptoms  did  no!  3eem  to  in- 


Fig.  180.— Advanced  Stage  of  Osteomyelitis  of  Tibia. 

dicate  an  acute  inflammatory  process.  Pain  being  present  only 
temporarily,  the  development  of  a  malignant  growth  was  feared. 
The  skiagraph  at  once  did  away  with  all  anxiety,  since  it  revealed 
the  presence  of  periostitic  proliferation  and  a  circumscribed  osteo- 


252  THE    KONTGEN    KAYS 

myelitic  focus  at  the  middle  of  the  humerus.  The  focus  was  easily 
exposed  by  the  chisel  under  the  mentorship  of  the  skiagram.  That 
the  skiagram  had  also  spoken  the  truth  by  demonstrating  the  in- 


Fig.  181. — Extensive  Osteomyelitis  at  the  Point  of  Perforation. 

tegrity  of  the  remaining  portions  of  the  humerus  was  shown  by 
the  speedy  recovery  of  the  patient. 

Thus  the  foci  can  not  only  be  localized,  but  their  extent  can  also 
be  so  well  outlined  that  the  technical  steps  of  the  operation  can  be 
definitely  traced  in  advance.  The  feeling  of  security  the  surgeon 
has  while  proceeding  under  the  mentorship  of  the  skiagraph  gives 
a  satisfaction  unknown  in  former  years,  when  often  the  whole 
bone,  like  the  femur,  for  instance,  had  to  be  exposed  in  order  to 
ascertain  whether  all  the  foci  had  been  detected.  If  the  Eontgen 
rays  show  but  one  focus,  no  other  regions  of  the  bone  need  to  be 
attacked.  Fig.  179  shows  the  osteomyelitic  focus  in  the  lower 
third  of  the  humerus  of  a  woman  of  thirty  years.  The  patient  was 
treated  for  rheumatism  first.  When  seen  by  the  author,  two  weeks 
after  the  onset  of  the  violent  pain  in  the  lower  region  of  the 
humerus,  a  slight  swelling  and  tenderness  at  this  region  was 
noticeable.  Skiagraphy  revealed  the  focus  and  dictated  the 
modus  operandi.    A  tablespoonful  of  staphylococcus  pus  was  dis- 


DISEASES   OF   THE   BOXES    AND   JOINTS        253 


charged  and  the  cavity  packed  with  iodoform  gauze.  Recovery 
was  perfect  after  two  months.  In  former  years  the  diagnosis  a1  so 
early  a  stage  would  not  have  been  possible,  and  consequently  so 
speedy  a  recovery  would  not  have  been  obtained.  In  this  case  an 
injury  of  the  tibia,  followed  by  suppuration,  had  been  sustained 
six  months  previously. 

The  osteomyelitic  focus  is  distinguished  by  its  light  shadow  in 
the  midst  of  the  dark  shadow  of  the  thickened  cortex.  The  regu- 
larity of  the  cortical  line  distinguishes  it  from  osteosarcoma,  and 
the  absence  of  distention  from  osseous  cyst. 

In  the  more  advanced  stages  the  cortex  and  periosteum  par- 
ticipate in  the  process.  Then  the  skiagraph  naturally  shows  pro- 
portional changes.  The  shadow  of  the  sclerotic  cortex  becomes 
still  larger  and  the  ossifying  inflammation  of  the  periosteum  finds 
its  skiagraphic  expression  in 
a  very  light  shadow-line  run- 
ning parallel  to  that  dark- 
one  of  the  cortex. 

Fig.  180  illustrates  the  ad- 
vanced stage  of  osteomyelitis 
at  the  upper  end  of  the  tibia 
in  a  man  of  thirty  years.  At 
the  anterior  aspect  of  the 
bone  perforation  had  already 
taken  place,  while  posteriorly 
the  cortex  is  still  intact.  The 
evacuation  of  the  focus  was 
easy  and  recovery  was  per- 
fect. 

In  tubercular  abcesses 
sclerosis,  or  rather  eburna- 
tion,  is  extremely  rare,  which 
is  of  importance  in  the  ques- 
tion of  differentiation.  After 
extensive  operations  for  os- 
teomyelitis, eburnation  of  the  cortex  is  so  marked  that  the  con- 
trast appears  most  striking  on  the  skiagraphic  plate. 

Fig.  181  illustrates  osteomyelitis  of  the  tibia  in  a  girl  of  fifteen 
months  in  an  advanced  stage.  The  child,  having  sustained  a  fall 
from  her  cradle  several  weeks  before  being  skiagraphed,  was  sup- 


Pie.  182.— Osteomyelitic  Focus  in  the 
Tibia.    (Compare  Fig.  181.) 


254 


THE    RONTGEN    EAYS 


posed  to  have  suffered  a  severe  contusion,  and  was  treated  accord- 
ingly. The  external  swelling  was  insignificant.  No  fluctuation 
being  present,  the  attendant  did  not  think  of  the  possibility  of  the 
presence  of  suppuration,  although  the  patient's  temperature  was 
elevated  once  in  a  while.  Skiagraphic  examination  proved  the 
presence  of  an  extensive  osteomyelitic  focus,  which  was  at  once  ex- 
posed by  the  chisel.  Two  tablespoonfuls  of  pus  were  discharged 
the  recovery  being  uninterrupted.  Fig.  182  shows  the  cavity 
three  weeks  after  operation.  The  dark  shadow  lining  the  mar- 
gins of  the  cavity  indicates  the  presence  of  iodoform. 


NECROSIS 

Necrosis  and  other  later  stages  of  inflammatory  processes  can 
be  represented  still  more  distinctly. 

The  size  and  shape  of  sequestra  can  be  well  made  out.  It  can 
furthermore  be  ascertained  how  they  are  located  in  their  bony 


Fig.  183. — Sequestrum  Exfoliating  from  the  Radius. 


coffin,  and  whether  they  still  adhere  or  are  exfoliated.     Under  the 
guidance  of  the  Rontgen  rays  extraction  is  very  easy. 


DISEASES   OF   THE    BONES    AXI)   JOINTS        255 

Fig.  183  illustrates  the  case  of  a  man  of  twenty-three  years 
who  had  crushed  his  little  left  finger.  Amputation  was  deferred 
until  septic  tenontitis  and   tenontothecitis  had  developed.     The 


Fig.  184. — Osteoperiostitis  following  Phlegmon  of  Hand. 


extensive  tissue  necrosis  in  the  muscular  interstices  of  the  forearm 
necessitated  free  and  deep  incisions,  which  showed  the  radius  as 
well  as  the  ulna  denuded  of  their  periosteum.  Amputation  was 
therefore  authoritatively  advised;  nevertheless,  the  chances  of  fur- 
ther conservative  treatment  were  taken.  The  author's  experience 
had  taught  him  to  resort  to  amputation  for  sepsis  only  under  the 
most  extraordinary  circumstances;  and  it  seems  to  him  that  all 
cases  which  were  saved  by  amputation  would  have  recovered  under 
the  most  vigorous  conservative  measures,  especially  excessive  expo- 
sure of  the  foci  and  removal  of  suspicious  tissue.  Fortunately,  the 
process  became  confined  to  the  forearm,  and  recovery  seemed  to 
make  rapid  progress.  Only  a  small  fistula  at  the  dorsum  of  the 
forearm  did  not  close.  The  repeated  introduction  of  a  probe  did 
not  point  to  the  presence  of  rough  bone,  and  the  author  was  in- 
clined to  suppress  his  suspicion  of  the  presence  of  a  sequestrum. 
His  surprise  was  great  when  the  Eontgen  rays  revealed  so  large  a 


256  THE    KONTGEN    RAYS 

splinter  as  that  which  is  shown  by  the  skiagraph.  The  direction 
of  the  skin  incision,  a  slightly  oblique  one,  was  dictated  by  the 
position  of  the  sequestrum  as  indicated  by  the  skiagraph.     When 


Pig.  185.    Synostosis  between  Radius  and  Ulna  and  Exfoliating  Sequestrum. 

the  sequestrum  was  reached,  it  was  found  covered  by  thick  fibrous 
tissue  at  the  upper  surface,  while  the  inner  and  lower  surfaces  were 
exposed.  This  explains  why  the  introduction  of  the  probe  gave  no 
positive  information,  since  it  had  touched  only  the  fibrous  cover, 
and  did  not  come  into  contact  with  the  rough  lateral  or  posterior 
surface.  Recovery  was  perfect  eleven  days  after  the  operation. 
The  translucent  state  of  the  bones  due  to  inflammatory  atrophy 
is  also  noteworthy. 

The  regeneration  of  osseous  tissue  can  be  well  studied  in  such 
cases  by  the  skiagraph. 

That  the  bones  participate  in  acute  phlegmonous  processes  is 
evident  from  Fig.  184,  which  illustrates  the  hand  of  a  man  of 
forty  years,  whose  left  little  finger  was  crushed  in  a  machine. 
Medical  treatment  was  not  submitted  to  until  the  whole  hand  be- 
came swollen.     A  septic  phlegmon  developed,  which  necessitated 


DISEASES   OF   THE   BONES    AM)   JOINTS        257 

extensive  incisions.  When  the  swelling  had  subsided  thickened 
bone  portions  could  be  palpated,  the  osteoperiostitic  nature  of 
which  was  shown  by  the  skiagraph. 

Before  the  advent  of  the  rays  such  extensive  participations  of 
the  bones  could  not  have  been  assumed.     Later  observation  often 


Fig.  186. — Sequestrum  in  the  Femur. 


showed  osseons  changes  in  apparently  slight  cases  of  inflammation 
of  an  infectious  origin.  This  shows  the  eventual  necessity  of  ex- 
posing intraosseous  foci  when  operating  for  phlegmon. 

Fig.  185  illustrates  the  sequela?  of  puerperal  sepsis  in  a  woman 
18 


258  THE    RONTGEN    RAYS 

of  thirty-five  years.  Septic  arthritis  and  tenontitis  developed  after 
childbirth,  and  was  treated  by  extensive  exposure  of  the  foci.  Six 
months  after  the  operation  a  fistula  at  the  upper  end  of  the  radius 
remained,  the  cause  of  which  was  evident  by  the  presence  of  a 


Fig.    187. — Necrotic   Kadius  and   Arroded   Humerus,  covered  by  Iodoform 

Gauze. 

small  exfoliating  sequestrum,  shown  at  the  upper  portion  of  the 
ulna;  the  skiagraph  also  explained  why  rotation  of  the  forearm 
was  impossible,  since  it  showed  the  presence  of  synostosis  between 
the  radius  and  the  ulna,  undoubtedly  due  to  the  preceding  inflam- 
matory irritation.  Accordingly  the  illustration  suggests  separa- 
tion of  the  united  bones  by  the  chisel. 

As  to  further  details  regarding  sequestra  of  the  femur  after 
fracture,  the  reader  is  referred  to  the  cases  illustrated  by  Figs. 
100  and  101. 

Fig.  186  illustrates  the  case  of  a  man  of  twenty-three  years 
who  had  sustained  a  compound  fracture  of  the  middle  of  the 
femur  four  years  before  the  skiagraph  was  taken.  The  patient 
suffered  from  more  or  less  severe  inflammatory  attacks  now  and 
then,  pus  discharging  frequently  from  a  fistula  at  the  lower  third 
of  the  thigh.  Skiagraphy  at  first  showed  nothing  but  the  deform- 
ity of  the  femur,  because  a  soft  tube  had  been  selected,  while  a  tube 


DISEASES   OF   THE   BOXES   AX  I)   JOINTS        259 

of  medium  hardness  revealed  the  presence  of  a  small  piece  of 
necrotic  bone  in  its  coffin  at  the  area  of  the  fracture.  The  se- 
questrum was  extracted  through  a  small  opening  made  as  the 
skiagraph  indicated  it,  recovery  being  perfect. 

Fig.  187  illustrates  necrosis  of  the  inner  half  of  the  radius 
in  a  girl  of  seventeen  months.  The  first  signs  of  inflammation 
manifested  themselves  live  weeks  before  the  skiagraph  was  taken. 
At  first  an  injury  was  thought  of.  The  Rontgen  method  revealed 
the  true  nature  of  the  disease  at  once,  and  suggested  exposure  of 
the  radius.  When  this  operation  was  performed  the  impression 
was  that  the  radius  had  become  a  uniform  sequestrum,  and  in 
former  years  the  author  would  therefore  have  removed  the  bone 
in  its  entirety.  But  the  skiagraph  indicated  that  the  outer  por- 
tion of  the  bone  was  normal,  therefore  the  inner  side  was  removed 
by  the  sharp  spoon,  so  that  only  a  thin  long  fragment  remained, 


Fig.     188. — Remnant   of  Radius,    showing    Beginning    Bone     Proliferation 
after  Removal  of  .Necrotic  Area.     (Compare  Fig.  187.) 


which  was  carefully  left  in  contact  with  the  remnant  of  the  peri- 
osteum. In  spite  of  the  emaciated  condition  of  the  patient  perfect 
recovery  took  place,  the  function  of  the  extremity  being  completely 
restored. 

Fig.   188  illustrates  the  case  two  weeks  after  operation,  the 
iodoform-gauze  packing  also  appearing  marked  on  the  skiagraph. 


260  THE    RONTGEN    RAYS 


ACUTE  INFLAMMATORY  ATROPHY  OF  THE  OSSEOUS 

TISSUES 

The  peculiar  character  of  the  bone  shadows  shown  in  inflam- 
matory processes,  which  seemed  to  be  confined  to  the  soft  tissues 
exclusively,  suggested  that  such  pathological  changes  had  also  ex- 
tended upon  the  bony  tissues.  The  similarity  of  the  shadows  to 
those  found  in  rickets  or  osteomalacia  led  to  the  belief  that  an 
acute  absorption  of  calcareous  matter  had  taken  place.  More  ex- 
tensive observation  showed  that  these  phenomena  generally  made 
their  appearance  four  to  nine  weeks  after  the  injury. 

Before  the  Rontgen  era  the  clinical  symptoms  caused  by  them 
were  attributed  to  inactivity,  but  skiagraphy  proved  that  the 
osseous  tissues  underlying  the  inflammatory  area  participated,  the 
spongiosa  showing  the  first  signs  of  change.  Sudeck  (Archiv 
fur  klinische  Chirurgie,  vol.  lxii)  and  Kienboeck  (Wiener  medi- 
cinische  Wochenschrift,  No.  28,  1901)  advanced  the  theory  that 
bacterial  invasion  was  arrested  at  the  spongiosa  in  mild  forms 
(fractures,  for  instance),  only  the  signs  of  congestion  and  swell- 
ing, etc.,  being  present.  But  in  the  virulent  cases,  as  in  septic 
phlegmon,  septic  tenonitis,  etc.,  bacteria  have  reached  the 
medulla.  Then  the  tissue  changes  are  more  marked  and  conse- 
quently show  the  skiagraph  evidence. 

Rarefaction  of  the  osseous  tissue  can  be  recognised  by  the 
presence  of  some  light  areas.  In  the  more  severe  forms  the  cortex 
becomes  less  compact,  the  translucency  reaches  a  high  degree,  and 
the  texture  disappears  entirely. 

In  phlegmonous  processes,  septic  arthritis,  etc.,  rarefaction 
may  reach  such  a  degree  that  portions  of  the  bones  become  so 
soft  temporarily  that  an  aspiratory  needle  may  perforate  them 
without  resistance.  Such  bones  are,  of  course,  highly  translucent, 
and  consequently  show  very  light  shadows  on  the  Rontgen  plate. 
The  osseous  structure  may  appear  confused  and  blurred,  the  tra- 
becular become  thinner  and  disappear  altogether  in  some  areas. 
As  alluded  to  before,  these  conditions  resemble  osteomalacia,  but 
the  process  of  calcification  in  these  cases  is  of  a  decidedly  inflam- 
matory nature. 

In  a  case  of  old  pyothorax  (see  Zwanglose  Hefte,  Die  Ront- 
genstrahlen  in  der  Chirurgie,  Seitz  und  Schauer,  Miinchen,  1901) 


DISEASES   OF   THE   BONES   AND   JOINTS        261 

the  author  did  no1  succeed  in  reproducing  the  ribs  of  a  man  who 

had  submitted  to  resection  five  times.     At  first  a  technical  fault 


Fig.  189. — Traumatic  Atrophy  of  Shoulder-joint  and  Humerus,  followed 
by  Relaxation  of  Ligaments  (Sub-luxation) — Posterior  Exposure. 
(Compare  Pig.  190.) 

was  supposed  to  be  the  cause,  when  a  renewed  resection,  this  time 
performed  by  the  author  himself,  called  his  attention  to  the  soft- 
ened condition  of  the  ribs,  which  accounted  for  the  lack  of  skia- 


262 


THE    RONTGEN    RAYS 


graphic  contrast.     In  tuberculous  processes,  associated  with  sup- 
puration,  the   same    osseous   rarefaction   is    observed    sometimes. 


Fig.  190.— Same  as  Fig.  189— Anterior  Exposure. 


After  fractures,  caused  by  great  violence,  similar  osseous  changes 
are  noticed. 

The   author  has   in   former  publications    (see  TJeber   deform 


DISEASES   OF   THE   BONES   AND   JOINTS        263 

geheilte  Fracturen,  Munich  Medical  Weekly,   February  17,  1901) 

called  attention  to  the  intense  absorption  of  calcareous  matter  in 
syphilitic  gumma  and  in  carcinoma  and  sarcoma  (see  respective 
sections).  Fig.  118  illustrates  the  case  of  a  man  of  thirty-eighl 
years  who  sustained  a  fracture  of  the  calcaneum  two  months  before 
the  skiagraph  was  taken,  which  showed  a  high  degree  of  trans- 
lucency.  At  first  the  impression  that  this  was  a  fault  of  the 
technique  prevailed,  but  repeated  exposures  showed  the  same  con- 
ditions. The  great  functional  disturbance  was  not  in  proportion 
to  the  slightly  deformed  union,  therefore  it  had  to  be  assume! 
that  it  was  due  to  the  acute  inflammatory  atrophy  of  the  bone. 

If  the  primary  focus  heals  rapidly,  the  softening  of  the  bones 
may  last  but  a  few  weeks,  perfect  recovery  taking  place  then.  But 
not  infrequently  the  process  proceeds  further,  the  diaphyseal  cor- 
tex also  becoming  affected.  Then  deformity  of  the  bones  takes 
place,  and  the  cartilage  shows  signs  of  erosion.  While  in  the 
acute  stage  the  osseous  tissues  are  hypersemic  and  softened,  later 
on  this  becomes  anaemic  and  brittle.  The  ligaments  may  be  so 
much  relaxed  then  that  a  condition  resembling  dislocation  forms. 
In  children  the  natural  growth  of  the  bone  may  be  arrested,  so 
that  considerable  shortening  takes  place. 

Figs.  189  and  190  illustrate  a  condition  of  ibis  kind  in  a 
man  of  nineteen  years,  whose  shoulder  was  severely  injured  at 
childbirth.  It  is  reported  that  after  the  inflammatory  signs  in  the 
joint  had  subsided,  atrophy  of  the  whole  area  developed.  At  the 
time  of  irradiation  the  left  humerus  proved  to  be  an  inch  shorter 
than  its  fellow.  The  articular  surfaces  were  irregular,  and  the 
area  of  the  tubercles  still  translucent.  The  deformity  of  the 
acromion  as  well  as  of  the  coracoicl  process  is  well  marked.  The 
subluxation  appears  more  pronounced  in  the  anterior  than  in  the 
posterior  exposure.     There  is  severe  functional  disturbance. 

The  great  importance  of  inflammatory  atrophy,  which  at 
least  delays  recovery  strangely,  and  in  some  instances  may  neces- 
sitate amputation,  is  self-evident  from  a  medico-legal  standpoint 
(see  Chapter  XVII  on  Medico-Legal  Aspects).  Another  peculi- 
arity of  atrophic  bones  is  that  they  are  more  inclined  to  become 
fractured  than  normal  ones. 

As  the  pathogenic  nature  of  acute  inflammatory  atrophy  still 
appears  to  be  obscure,  the  main  factor  in  its  astiology  seems  to  be  a 
disturbance  in  the  circulation,  probably  of  a  trophoneurotic  char- 
acter. 


264 


THE  KONTGEN  EAYS 


TUBEKCULOSIS 

As  emphasized  in  the  chapter  on  tuberculosis  of  the  lungs, 
the  clinical  signs  of  tuberculosis  are  but  little  marked  at  its  early 
stage.     The  same  applies  to  bony  tuberculosis.     This  is  deplorable, 


Fig.  191.— Enlargement  of   Internal  Condyle,  causing  Valgus  Position  of 
Knee,  in  Tuberculosis.     (Compare  Fig.  192.) 


for  the  reason  that  therapy  is  much  more  effective  at  the  initial 
stage  than  when  the  symptoms  are  well  marked — in  other  words, 
when  the  process  of  destruction  has  become  advanced.  It  is,  in- 
deed, not  at  all  difficult  to  diagnosticate  osseous  tuberculosis  if 
there  be  the  characteristic  appearance  of  fistulous  tracts,  discharg- 
ing cheesy  pus,  the  simultaneous  development  of  tuberculosis  of 
the  lungs  or  of  other  internal  organs,  and  last  but  not  least,  a  his- 
tory of  tuberculosis. 

Fortunately,  the  Eontgen  rays  enable  us  to  recognise  a  tubercu- 
lous focus  at  an  early  stage,  thus  giving  the  surgeon  a  chance  to 


DISEASES   OF   THE    BONES    AND   JOINTS        265 

perform  a  conservative  operation,  while  ai  the  Late  stage  of  exten- 
sive destruction  such  effects  prove  to  be  futile. 

A  slight  swelling  of  one  of  the  tarsal  bones  may  be  regarded 
to  be  the  result  of  a  contusion,  while  the  rays  prove  it  to  be  pro- 
duced by  a  tuberculous  focus,  the  speedy  elimination  of  which 
means  a  perfect  cure  from  a  tubercular  process.  One  of  the 
prominent  features  of  bone-tuberculosis  is  its  prevalence  at  the 
epiphyses.  This  naturally  causes  such  characteristic  changes  in 
the  articular  ends  that  they  can  be  represented  skiagraphically.  At 
the  early  stage  of  tuberculosis  osseous  atrophy  at  the  epiphyseal 
ends  is  always  found  to  a  greater  or  lesser  extent,  which  is  pro- 
duced by  a  deficiency  of  calcareous  deposits. 

The  less  calcareous  substance  the  atrophic  area  contains,  the 
more  translucent  it  becomes  by  the  rays,  thus  showing  a  character- 
istic light  shadow.  In  late  stages  when  cheesy  foei  form,  their 
areas  appear  still  more  translucent. 

As  a  rule,  the  articular  outlines  of  a  tuberculous  joint  have 
lost  their  regularity  and  appear  diffuse,  cloudy,  and  often  shaggy. 


Fig.  192.— Tuberculous  Knee-joint  after  Osteotomy.     (Compare  Fig.  191.) 

The  cortex  is  sometimes  partially  destroyed,  and  leaves  the  im- 
pression as  if  a  piece  had  heen  bitten  out,  as  in  Fig.  191,  for  in- 
stance, which  shows  enlargement  of  the  internal  condyle  at  the 


266  THE    KOXTGEN    RAYS 

same  time.  After  the  process  came  to  a  standstill,  the  deformity 
became  so  great  that  cuneiform  osteotomy  was  done  (see  Fig. 
192). 

Fig.  193  illustrates  a  moderate  degree  of  tuberculosis  in  a  boy 
of  five  years,  the  cartilages  being  eroded.  Such  cases  generally 
get  well  after  the  injection  of  iodoform  glycerin. 

After  thorough  repair  the  area  of  the  primary  focus  gradually 
indicates  its  normal  saturation  on  the  skiagraphic  plate  again. 
The  texture,  however,  has  lost  its  distinct  character,  the  network 
showing  wider  meshes.  Only  the  contours  of  the  cortex  are  well 
marked,  sometimes  even  more  than  before. 

Fig.  194  illustrates  enlargement  of  hoth  internal  condyles 
of  the  femur  in  a  boy  of  fourteen  years,  four  months  after  his 


Fig.  193. — Tuberculous  Knee,  showing  Arrosion  of  Cartilages. 

tuberculous  gonitis  was  cured  by  the  injection  of  iodoform-glyc- 
erin.  The  left  knee  seems  to  be  perfectly  restored,  while  the 
articular  surfaces  of  the  right  knee  are  somewhat  shaggy. 


DISEASES   OF   THE   BONKS    AND   JOINTS        207 

In  the  case  of  extensive  tubercular  destruction  the  eroded  and 
displaced  cartilages  can  be  studied. 

Fig.  195,  for  instance,  illustrates  the  tubercular  knee  of  a  boy 
of  four  years.     The  texture  of  the  hone,  the  medulla,  and  the  e.\- 


Fig.  194.— Enlargement  of  Both  Internal  Condyles  in  a  Boy  of  Fourteen 
Years,  Four  Months  after  his  Tuberculous  Gonitis  was  Cured  by  the 
Injection  of  Iodoform-glycerine. 

tensive  destruction  of  the  cartilaginous  tissues  are  well  marked 
in  the  skiagraph,  Fig.  19G.  A  tube  of  medium  hardness  was 
selected  to  show  these  structural  details,  while  a  soft  tube  which 
was  employed  before  showed  only  the  backward  dislocation  pro- 
duced by  the  erosion  of  the  ligaments,  but  no  foci. 

Fig.  197  shows  synostosis  between  patella  and  femur  as  a 
consequence  of  tuberculous  inflammation,  valgus  position  being 
present  besides.  After  the  process  had  stopped,  osteotomy  of  the 
condyle  was  performed.  Later  the  synostosis  between  patella  and 
femur  was  divided  by  the  chisel. 

In  tubercular  coxitis,  the  spontaneous  upward  dislocation  of 


268 


THE    KONTGEN    KAYS 


the  femur  and  the  separation  of  its  head  in  the  acetabulum  is  rec- 
ognised. In  obscure  cases  the  rays  differentiate  it  from  rheuma- 
tism, arthritis  deformans,  congenital  dislocation,  fracture  of  the 

neck  of  the  femur,  epiphyseal  separa- 
tion, neuralgia,  or  osteomyelitis.  The 
healthy  joint  must  always  be  skia- 
graphed  at  the  same  time  for  com- 
parison. Fig.  98,  for  instance,  illus- 
trates the  tuberculous  hip-joint  of  a 
boy  of  eleven  years  a  year  after  the 
onset  of  the  disease.  The  articular  out- 
lines appear  irregular,  cloudy,  and  on 
some  portions  shaggy.  Eecovery  took 
place  in  this  instance  after  resection. 
The  extent  of  the  destruction,  as  it  is 
shown  by  the  skiagraph,  determines  the 
question  whether  resection  must  be  re- 
sorted to  or  whether  conservative  steps 
are  justified. 

Fig,  198  shows  the  destruction  of 
the  left  parietal  bone  and  part  of  the 
orbit  in  a  boy  of  ten  years.  How  far 
the  bone  became  decayed  is  illustrated 
by  the  light  area  in  Fig.  199. 

The  only  marked  signs  of  tubercu- 
lar spondylitis  consist  sometimes  in  the 
presence  of  an  abscess  below  Poupart's 
ligament,  the  nature  of  which  would 
not  be  properly  interpreted,  if  the 
plate  did  not  prove  the  existence  of 
vertebral  changes. 

Skiagraphs  of  the  hip-joint  should 
always  be  taken  by  using  a  diaphragm.  As  to  the  details  of  tuber- 
culosis of  the  hand,  see  section  on  Diseases  of  the  Hand  (page 
233).  How  cheesy  foci  of  cervical  and  bronchial  glands  are  shown 
is  illustrated  in  Chapters  VII  and  VIII  on  the  Neck  and  Chest. 

Extensive  deposition  of  calcareous  matter  in  the  sheaths  of  the 
tendons,  called  tenontitis  and  tenontothecitis  prolifera  calcarea  by 
the  author,  seems  to  bear  relations  to  tuberculosis. 

Fig.  200  illustrates  the  hand  of  a  Russian  tailor,  forty-two 


Fig.  195.  —  Photograph  o  f 
Case  of  Tuberculous 
Knee,  Illustrated  by 
Fig.  196. 


DISEASES   OF   THE    BOXES   AND   JOINTS        269 

years  of  age,  who  had  noticed  a  small  and  painless  -welling  formed 
in  the  dorsal  surface  of  his  right  hand  eleven  years  before.  This 
swelling  increased  gradually,  bul  until  it  grew  painful  no  medical 
advice  was  sought.  At  the  firsl  examination  a  globular  tumour 
was  noticed  in  the  dorsum  of  the  right  hand,  of  the  size  of  a 
moderately  large  apple.     Its  surface  was  red,  its  consistence  irreg- 


Fig.  196.— Tuberculous  Foci  In  and  Around  the  Knee-joint.     (See  Fig.  195.) 

ular,  some  parts  of  it  being  hard,  while  others  appeared  soft  to  the 
touch.  The  centre  of  the  tumour  was  occupied  by  a  large  ulcera- 
tion, which  was  surrounded  by  several  fistulous  tracts,  from  which 
turbid  sero-pus  issued.  The  first  impression  was  that  the  tumour 
represented  an  osteosarcoma,  and  it  was  feared  that  speedy  ampu- 
tation would  be  indicated.  It  was  decided  to  make  use  of  the 
Rontgen  rays,  which  proved  to  be  a  valuable  means  of  information, 
since  the  true  condition  was  at  once  precisely  defined.  A  skia- 
graph, which  was  taken  with  a  tube  of  medium  hardness  (Fig. 
201),  showed  that  the  third  metacarpophalangeal  joint  was  the 


270 


THE    RONTGEN    RAYS 


Fig.  197. —Synostosis   Between    Patel- 
la and  Femur,  before  Operation. 


seat  of  a  focus  of  inflammation.    The  phalanx  was  grown  together 
with  the  metacarpus.     The  cortex  of  the  condylar  side  was  totally 

destroyed,  appearing  as  if 
scooped  out  with  a  gouge.  By 
irradiation  with  a  soft  tube 
the  limits  of  the  tumour  were 
well  outlined.  A  third  skia- 
graph, taken  with  a  hard 
tube,  showed  the  bones  faint- 
ly, but  permitted  distinct  rec- 
ognition of  the  various  shad- 
ows of  the  tumorous  portions. 
The  light  areas  represented 
the  suppurating  portions, 
while  the  dark  shadows  cor- 
responded to  the  calcareous 
areas.  These,  as  shown  also 
by  subsequent  operation,  were 
the  predominating  elements  of  the  tumour.  It  now  became  evi- 
dent that  there  was  a  chronic  inflammatory  process,  the  character 
of  which  was  not  recognized. 

Extirpation  showed  the  defect  of  the  bone  filled  with  yellow 
cheesy  masses,  the  synovial 
membrane  being  partially  de- 
stroyed at  the  same  time.  But 
the  most  surprising  feature  of 
the  condition  was  that  the  ex- 
tensor tendons  of  the  digits, 
excepting  the  thumb,  ap- 
peared as  if  cemented  into 
one  mass  of  mortar.  In  divid- 
ing this  mass  the  knife  caused 
a  loud  grating  sound.  Of 
the  tendon  on  the  third  finger 
only  a  few  rudimentary  fasci- 
cles had  remained,  so  that  it 
had  to  be  sacrificed  entirely. 
The  fascicles  of  the  second 
and  fourth  extensor  tendons 
were  kept  apart  by  the  conere- 


Fig.    198.— Exophthalmos     caused    by 
Tuberculous  Destruction  of  Skull. 


DISEASES   OF   THE    BONES   AND   JOINTS 


271 


lions.  They  were,  in  fact,  so  much  encrusted  thai  only  a  small  por- 
tion could  be  felt.  The  weight  of  the  whole  amount  of  calcareous 
mass  removed  proved  to  be  80  grammes. 

The  hones  of  the  forearms  showed  considerable  translucency, 
which  suggested  the  presence  of  an  atrophic  state  in  the  osseous 
system. 

Microscopical  examination  showed  round-cell  granulations  and 
the  presence  of  staphylococci,  but  no  evidence  of  tubercle  bacilli. 
There  were  also  deposits  of  phosphates  and  carbonates  of  calcium. 


Fig.  199. — Skiagraph  of  Case  Illustrated  by  Fig.  198. 


The  decalcified  fragments  of  the  tendons  showed  granulation  of 
the  circumfascicular  and  intrafascicular  connective  tissues,  also 
partial  necrosis.  Hematoxylin  stained  the  degenerated  tissue 
dark  brown  violet,  and  picrocarmine  changed  it  to  red.  Eecoverv 
was  slow  and  was  not  perfect  until  six  months  after  the  operation. 
Now,  what  was  the  integral  character  of  the  disease?  There 
was  a  much  degeneratel  (cheesy)  tissue  in  the  state  of  necrobiosis, 
which  seemed  to  have  a  sort  of  magnetic  effect,  so  to  speak,  on  the 
dissolved   calcareous  salts,  inducing  them  to  amalgamate.     Such 


272 


THE    KONTGEN    RAYS 


Fig.  200.— Swelling  of  Hand  in  Tenontitis  and  Tenontothecitis  Prolifera 
Calcarea.     (See  Fig.  201.) 

petrifications  are  found  in  tuberculous  (cheesy)  foci  of  the  lungs, 
and  not  infrequently  in  endocarditis,  pericarditis,  old  pleuritic 
bands,  uterine  myomata,  and  renal  epithelium.     As  to  definition 


Fig.  201. — Tenontitis  and  Tenontothecitis  Prolifera  Calcarea. 
(See  Fig.  200.) 


DISEASES   OF   THE   BONES   AND   JOINTS        273 

by  means  of  the  Eontgen  rays  to  the  mode  of  petrification  in  the 
walls  of  blood-vessels  as  well  as  in  the  degenerated  thyroid  gland, 
see  the  respective  sections. 

The  tendons  and  their  sheaths  seem  to  be  but  seldom  the  seat 
of  predilection  for  calcareous  deposits.  Still,  with  the  increasing 
popularity  of  the  Eontgen  rays,  more  light  may  also  be  thrown 
upon  the  pathology  and  significance  of  this  hitherto  unknown 
disease,  for  which  the  term  "  tenontitis  and  tenontothecitis  prolif- 
era  calcarea  "  is  suggested. 

Wolff  (Archiv  fiir  klinische  Chirurgie,  67  Bd.,  Heft  2,  1902) 
reports  a  similar  observation,  calcareous  deposits  being  found  in 
the  tendon  and  fibrous  portions  of  the  semitendinosus  muscle. 
His  patient  being  sixty  years  of  age,  he  regards  the  case  as  one 
of  senile  calcification.  The  author,  however,  does  not  believe  that 
the  age  is  of  material  influence  upon  the  production  of  calcareous 
matter  in  this  connection. 


EHACHITIS   (EICKETS) 

Ehachitis,  while  frequently  found  in  Europe  (in  the  old  uni- 
versity town  of  Halle,  which  is  situated  in  midst  of  the  German 
potato  district,  47  per  cent  of  all  children  suffer  from  rhachitis), 
is  but  seldom  observed  in  the  United  States.  Nothing,  in  fact, 
demonstrates  the  prosperity  of  this  country  more  markedly  than 
the  absence  of  this  disease,  which  owes  its  origin  mainly  to  poor 
nutrition. 

As  is  well  known,  the  characteristic  features  of  rhachitis  con- 
sist in  a  change  of  the  composition,  form,  and  texture  of  the 
bone,  due  to  the  absence  of  the  normal  amount  of  calcareous 
deposits  during  the  period  of  development.  This  is  recognised 
macroscopically  by  the  development  of  more  or  less  deformity 
(Fig.  202).  The  cartilaginous  substance  proliferates  to  such  an 
extent  that  the  epiphyses  become  more  or  less  enlarged.  The  calci- 
fication line,  characteristic  of  the  normal  osseous  growth,  is  found 
to  be  entirely  changed.  While  the  areas  of  cartilaginous  and  osse- 
ous proliferation  in  a  normal  individual  show  regular  lines,  which 
run  parallel  to  each  other,  they  appear  irregular  and  zigzag-shaped 
in  a  rachitic.  These  changes  appear  like  indentations  in  the  longi- 
tudinal section  of  a  rhachitic  epiphysis.  The  different  degrees  of 
19 


274 


THE    RONTGEN    EAYS 


density  caused  by  such  changes 
can  be  well  reproduced  by  the 
rays.  Besides  its  character- 
istic architecture  the  bone 
shows  some  marked  peculiari- 
ties. The  abnormality  of  the 
process  of  calcification  is  most 
evident  at  the  femur,  the  tibia, 
and  fibula,  the  lower  end  of 
radius  and  ulna,  the  metacar- 
pal bones,  and  the  ribs. 

Fig.  203  shows  the  de- 
formed tibia  of  a  child  of  four 
years.  The  homogeneous 
structure  and  the  normal  den- 
sity of  the  middle  of  the  di- 
aphysis  point  to  sufficient  per- 
centage of  calcareous  matter, 
while  the  lower  third  shows 
considerable  lacking  of  these 
elements.  The  changes  in 
rachitis  slightly  resemble  those 
of  osteomalacia.  But  in  ra- 
chitis the  area  lacking  the  cal- 
careous matter  is  represented  by  newly  formed  and  osteoid  tissue, 
while  in  osteomalacia  it  is  formed  by  decalcified  bone.     Rachitis 


f+1». 


Pig 


202  — Rhachitic    Deformity   of 
Lower  Extremities. 


Fig.  203.— Rhachitic  Tibia. 


DISEASES   OF   THE   BONES   AND   JOINTS        275 

is,  however,  mainly  distinguished  from  osteomalacia  by  the  irregu- 
lar arrangement  of  interspersed  osseous  structures  as  well  as.  by 
the  deformed  shape  of  the  bones. 


OSTEOMALACIA 

As  alluded  to  in  the  foregoing  section,  there  is  a  greal  resem- 
blance between  rachitis  and  osteomalacia.  Still,  while  rachitis  is 
a  disease  of  infancy  and  childhood,  osteomalacia  is  found  in 
adult  life  only,  especially  in  puerperal  women.  It  consists  in  a 
progressive  softening  of  the  osseous  tissues.  In  rachitis  the  grow- 
ing bone  is  not  supplied  with  a  sufficient  quantity  of  lime-salts; 
in  osteomalacia  the  normal  amount  of  lime-salts,  present  origi- 
nally, becomes  gradually  absorbed,  thus  causing  deformities  and 
sometimes  even  fractures  of  the  area  involved. 

The  deformity  generally  begins  in  the  os  ilii  in  puerperal 
cases.  Later  on  the  spine  becomes  involved,  the  vertebra;  being 
compressed  against  one  another,  promontory  and  symphysis  also 
approximating.  The  extreme  preponderance  of  the  substance  of 
the  bone  naturally  impairs  its  density,  so  that  the  degree  of  trans- 
lucency  shown  by  the  rays  indicates  the  degree  of  the  disease. 
It  must  be  considered,  however,  that  an  overexposed  skiagraph 
may  leave  the  erroneous  impression  that  there  is  a  lack  of  the 
normal  amount  of  calcareous  matter.  This  will  occur  so  much 
easier,  since  so  large  a  bone-mass  as  the  pelvis  must  generally  be 
reproduced,  which  would  suggest  a  long  exposure  and  a  hard  tube. 
But  if  the  deformities,  especially  the  course  of  the  linea  innom- 
inata  and  the  typical  kink  of  the  pubic  bone  are  well  recognised,  no 
misinterpretation  can  occur. 

AETHEITIS 

In  acute  arthritis  no  anatomical  changes  may  he  revealed  by 
the  rays  except  that  the  presence  of  an  effusion  may  cause  disten- 
tion of  the  joint.  This  fact  is  recognised  by  the  increasing  gap 
between  the  articulating  epiphyses.  Later  on  the  contours  of  the 
bone  epiphysis  appear  irregular,  and  show  indentations  on  some 
portions,  while  others  are  veiled.  The  arthritic  deposits  are  recog- 
nisable as  light  shadows  of  the  deformed  epiphyses,  as  they  consist 


276 


THE    HONTGEN    RAYS 


of  translucent  uric-acid   salts,   while   their   periphery   is   distin- 
guished by  a  dark  sphere. 

The  deposits  can  be  represented  only  by  using  a  soft  tube,  since 


Fig.  204.— Arthritis. 


the  rays  from  a  hard  one  penetrate  them  to  such  an  extent  that 
they  would  leave  no  impression  on  the  photographic  plate. 

In  gonorrhoea!  arthritis  the  epiphyses,  the  affected  joint,  and 
sometimes  their  vicinity  appear  rarefied,  so  that  they  resemble 
the  pathological  changes  occurring  in  acute  inflammatory  atrophy 
(see  the  section  page  260).  Eapid  and  intense  absorption  of 
calcareous  matter  takes  place,  the  osseous  texture  in  general  be- 
comes confused,  the  contours  as  well  as  the  structures  of  the  spon- 
giosa  appearing  blurred. 

In  all  cases  of  gonorrhceal  arthritis  of  the  wrist  observed  by 
the  author,  the  carpus  appeared  extremely  light  and  the  contours 
somewhat  irregular.  The  carpal  bones  are  not  well  defined  indi- 
vidually, but  produce  the  impression  of  a  confluent  mass,  and  the 
radio-carpal  joint  shows  a  great  tendency  to  ankylosis,  because 
later  even  the  surfaces  of  the  cartilages  become  eroded.  In  more 
advanced  stages  the  whole  hand  may  be  shortened.  In  arthritis 
of  the  elbow,  knee,  or  hip  the  anatomical  changes  appear  less 


DISEASES   OF   THE    BONES   AND   JOINTS        277 

marked,  of  course,  than  in  the  wrist.  In  order  to  represent  the 
spongiosa  trabecule  well,  tubes  of  medium  hardness  musl  In- 
chosen.  The  distance  should  be  about  LO  inches  between  the  tubal 
wall  and  the  plate. 

The  effect  of  the  therapy  (interna]  treatment,  immobilisation 
and  counter  irritants  at  the  beginning)  should  be  controlled  by 
skiagraphy.  When  the  inflammatory  process  begins  to  subside, 
massage  and  exercise  should   he   advised   in   order    to   counteract 


Fig.   205. — Fracture   of  the   Coronoid   Process  or  the  Ulna,  followed  by 

Arthritis. 

synostosis,  which  is  especially  apt  to  form  between  radius  and 
scaphoid  bone.  When  the  stiff  joint  will  not  be  made  movable  by 
massage  and  electricity,  a  chisel  operation  is  the  only  effective  pro- 
cedure under  such  circumstances. 


278 


THE    EONTGEN    EAYS 


Fig.    206.  —  Luetic     Destruction   of  , 
Frontal  Bone. 


AETHEITIS  DEFOEMANS 

The  nature  of  arthritis 
deformans  is  virtually  the 
same  as  that  of  arthritis,  the 


Fig.  207. — Destruction  of  Frontal 
Bone.     (Compare  Figs.  206  and  208.) 


cartilaginous  surfaces  breaking  up  into  very  fine  filaments,  because 
the  substance  which  keeps  the  fibrillae  together  undergoes  the  proc- 


Fig.  208.- 


-Skiagraph  of  Necrotic  Fragments  after  Removal. 
(See  Figs  206  and  207.) 


DISEASES   OF   THE    BONES   AND   .JOINTS        27!) 

ess  of  absorption.     Then  the  cartilage  becomes  gradually  softened 
down,  and  at  last  eroded  through  the  friction  of  the  articulating 


Pig.  209.— Case  Illustrated  by  Figs.  206,  207,  and  208,  after  Operation. 

surfaces.      The   underlying   hone-tissue   may   finally   be   exposed, 
which   would   favour   proliferation   of   its   surface,   thus   causing 


280 


THE    RONTGEN    RAYS 


hyperostosis.  The  spongiosa  undergoes  absorption,  and,  just  like 
in  acute  inflammatory  atrophy,  the  trabeculse  disappear,  so  that  the 
whole  area  becomes  rarefied. 

These  anatomical  changes  could  not  be  diagnosticated  before 
the  Rontgen  era  except  by  dissection,  the  soft  areas  not  appearing 

any  softer  to  the  touch  than 
normal  bone-tissue.  The  skia- 
graph, of  course,  reveals  the 
osteitic  proliferations  as  well 
as  the  rarefaction  in  a  most 
marked  manner.  Sometimes 
there  is  perfect  synostosis,  at 
other  times  the  joint  seems  to 
have  disappeared  entirely. 

Eig.  204  illustrates  the 
arthritic  knee  of  a  man  of 
forty-four  years.  The  osteitic 
proliferations  are  abundant 
and  well  marked.  There  is 
synostosis,  which  explains  the 
complete  osseous  ankylosis. 
In  a  case  of  this  kind  the  re- 
moval of  the  proliferations  by 
the  chisel  is  advisable,  pro- 
vided the  patient's  age  and 
constitution  justifies  the  in- 
terference. 

Fig.  205  (see  chapter  on 
Medico-Legal  Aspects)  shows 
abundant  osseous  proliferation  as  well  as  rarefaction  of  the  elbow- 
joint  in  a  man  of  fifty  years.  Its  complication  with  fracture  of  the 
coronoid  process  of  the  ulna  makes  it  especially  interesting,  and 
shows  the  great  difficulties  of  a  correct  aetiological  appreciation. 


Pig.    210. — Destruction   of   Nose   and 

Left  Frontal  Sinus. 

(Compare  Fig.  211.) 


SYPHILIS 


Osseous  changes  may  take  place  during  all  stages  of  syphilis, 
but  as  a  rule  only  the  tertiary  stage  is  fit  for  skiagraphic  repre- 
sentation, the  ossifying  periostitis  of  that  period  being  well  repre- 


DISEASES   OK   THE    BONES   AND   JOINTS        281 


sentable.  Jn  rare  instances  the  secondary  stage  also  shows  marked 
signs.  The  seat  of  predilection  in  this  type  of  ossifying  periostitis, 
as  is  well  known,  is  the  skull.  But  the  technical  difficulties, 
alluded  to  in  the  General  Part,  prevent  its  clear  skiagraphic  repre- 
sentation in  the  great  majority  of  eases.  The  extremities  are  a 
much  more  desirable  object  for  skiagraphic  study,  and  ii  is  espe- 
cially the  tibia,  another  favourite  scat  of  syphilitic  periostitis, 
which  shows  skiagraphic  signs  well. 

At  the  early  stage  the  periosteum  ossifies  to  a  great  extent, 
which  finds  its  skiagraphic  expression  in  the  presence  of 
well-marked  and  regular 
shadows,  extending  par- 
allel to  the  normal  cor- 
tex. This  may  become  so 
dark  that  the  periosteal 
and  cortical  shadow 
merge  into  each  other, 
it  being  much  darker 
than  the  shadow  in 
tuberculous  periostitis, 
because  the  deposition 
of  calcareous  matter  in 
syphilitic  periostitis  is 
much  more  abundant. 
Differentiation  from  os- 
teomyelitis is  somewhat 
more  difficult  because 
this  affection  is  also  char- 
acterized by  the  abun- 
dant deposition  of  cal- 
careous salts.  But  in 
osteomyelitis  there  is 
nearly  always  the  dis- 
tention of  the  bone. 

In  order  to  interpret 
correctly  it  is,  of  course, 
necessary  to  know  the 
skiagraphic     features     of 

the  normal  bone,  the  main  characteristics  of  which  are  the  regu- 
larity of  its  shadows. 


Fig.  211. — Luetic  Destruction  of  Nose. 
(Compare  Fig.  210.) 


282 


THE    RONTGEN    RAYS 


Figs.  206  and  207  illustrate  the  skull  of  a  woman  of  thirty-five 
years,  who  gave  a  history  of  infection.  Clinical  examination  had 
revealed  the  presence  of  a  sequestrum  at  the  frontal  bone,  but  the 
skiagraph  (Fig.  208)  showed  that  there  were  two  large  necrotic 
fragments.     After  their  removal  recovery  took  place  (Fig.  209). 

Fig.  210  illustrates  complete  destruction  of  the  nose.  The 
extent  of  the  deficiency  is  evident  from  Fig.  211.  The  destruction 
of  the  left  frontal   sinus  required   removal  of  a   small   necrotic 


Fig.  212. — Luetic  Osteoperiostitis  of  Tibia. 
(Compare  with  Fig.  218,  illustrating  periosteal  sarcoma.) 


area  there.  After  an  effort  to  create  a  new  osseous  support  by 
transplantation  had  failed,  injections  of  paraffin  oil  were  resorted 
to.     After  twelve  injections,  made  at  intervals  of  three  to  four 


DISEASES   OF   TIIF    BONES   AND   JOINTS 


283 


days,  were  administered,  a  sufficient  amouni  of  tissue  wa,e  obtained 
to  enable  the  author  to  form  the  nostrils. 

Fig.  212  illustrates  the  periostitie  proliferation  of  the  tibia 
in  a  woman  of  forty  years.     The  clinical  diagnosis  oscillated  be- 


Fig.  313. — Syphilitic  Dactylitis  of  the  Phalangeal  Joint  of  the  Thumb. 


tween  tuberculosis  and  osteomyelitis,  but  the  skiagraph  pointed 
to  specific  nature.  Recovery  took  place  after  exposure  and  scraping 
in  combination  with  mixed  treatment. 

Fig.  213  illustrates  syphilitic  dactylitis  in  a  woman  of  thirty- 
five  years.  Fracture,  contusion,  rheumatism,  and  tuberculosis  had 
been  thought  of  before  the  skiagraph  suggested  the  advisability  of 
an  antiluetic  therapy. 


CHAPTER    XIV 

NEOPLASMS 

Osteosarcoma. — By  realizing  that  osteosarcoma  is  the  most  fre- 
quent of  morbid  osseous  growths,  and  that  of  all  tumours  sar- 
coma offers  the  gravest  prognosis,  the  importance  of  a  thorough 


Fig.  214— Recurrent  Periosteal  Sarcoma  of  Humerus.     (See  Fig.  215.) 

diagnosis  need  not  be  emphasized.  The  matrix  of  osteosarcoma, 
like  that  of  all  osseous  growths,  is  either  the  periosteum  or  the 
medulla,  in  combination  with  the  tissue  originating  from  the  pro- 
liferation. 

284 


NEOPLASMS 


285 


Periosteal  sarcoma  is  of  a   moderate  hardness,  and   contains 
either  round,  or  spindle,  or  polymorphous  cells.     It  attaches  itself 


Fig.  215. — Periosteal  Sarcoma  of  Humerus.     (See  Fig.  214.) 


to  the  hone  laterally,  hut  may  in  its  further  development  encircle 
it  entirely.  It  may  develop  into  real  osteosarcoma  at  a  later  stage, 
when  osseous  trabecular  are  formed.  The  skiagraph  of  periosteal 
sarcoma  is  characteristic,  since  it  shows  fine  spiculated  trabecular 
which  radiate  from  the  surface.  Periosteal  sarcoma  spreads  rap- 
idly and  is  highly  malignant.  Whenever  the  diagnosis  is  made, 
amputation  should  be  in- 
sisted upon. 

Fig.  214  illustrates  the 
rapidly  developing  perios- 
teal sarcoma  in  a  boy  of 
fifteen  years. 

Fig.  215  shows  the  re- 
sected head  of  the  humerus 
skiagraphed.  The  degree 
of  translucency  as  well  as 
the  periosteal  prolifera- 
tions appear  well  marked. 

Fiff.   216  illustrates  the  Fig.  216.— Osteosarcoma  of  Humerus. 


286  THE    BONTGEN    BAYS 

same  type  in  a  boy  of  twelve  years.     The  rapid  growth  of  the 

tumour  and  its  destructive  character  were  a  sad  feature  of  this  case. 

Fig.  217  illustrates  the  periosteal  type  in  the  tibia  of  a  man 

of  sixty  years.     The  spiculated  trabecule  radiating  from  the  sur- 


Pig.  217.— Periosteal  Sarcoma  of  the  Tibia  Radiating  into  the  Surround- 
ing Tissues.     (Compare  with  Fig.  212,  illustrating  lues.) 

face  into  the  surrounding  soft  tissues  can  be  distinctly  recognised 
in  the  front  as  well  as  in  the  rear  of  the  bone.  Amputation  was 
advised  at  once.  Microscopical  examination  proved  the  tumour 
to  be  a  giant-cell  sarcoma. 

Fig.  218  represents  osteosarcoma  of  the  right  elbow  in  a  man 
of  thirty  years.  The  skiagraph,  Fig.  219,  shows  the  bone  pro- 
liferation at  the  inner  point  of  the  ulna,  which  points  to  the 
periosteal  character.     The  extirpation  verified  the  diagnosis. 


NEOPLASMS 


2S7 


Sarcoma  originating  from  the  medulla  is  called  myelogenous, 
and  is  of  a  less  malignant  character.  It  may  be  classified  as  soft, 
hard,  alveolar,  and  multiple.  The  soft  myelogenous  variety 
shows  the  ordinary  texture,  the  predominating  feature  being  the 
presence  of  round  cells.  It  has  a  decidedly  more  benign  charac- 
ter than  the  periosteal  type,  and  therefore  justifies  a  conservative 
attempt — that  is,  extensive  extirpation.  Thus  the  great  practical 
value  of  skiagraphic  differentiation  is  established. 

Spontaneous  fracture  may  be  produced  by  the  carious  destruc- 
tion of  the  spongy  portion.  At  a  later  stage  the  osseous  shell  will 
yield,  the  sarcomatous  tissue  spreading  in  every  direction. 

This  variety  has  a  predilection  for  the  long  bones,  especially 
their  ends,  and  predominates  at  the  lower  epiphyses  of  the  femur, 
tibia,  humerus,  and  radius.     Skiagraphs  of  the  soft  myelogenous 
variety  show  the  absence 
of  osseous  tissue,  although 
small  fragments  of  it  are 
sometimes   left   here   and 
there. 

Fig.  220  illustrates  the 
faint  outlines  of  bone 
shell  in  the  soft  myelo- 
sarcoma of  a  woman  of 
twenty-eight  years  who 
had  fallen  on  her  hand 
while  it  was  in  dorsal 
flexion.  The  swelling  re- 
sulting from  the  fall  pro- 
duced the  impression  that 
a  fracture  of  the  lower 
end  of  the  radius  had  been 
sustained.  Three  months 
after  the  injury,  when  the 
author  saw  the  patient 
for  the  first  time,  a  small 
deformity  was  noticed,  just  as  it  is  observed  in  badly  united  frac- 
ture of  the  lower  radial  end ;  but  the  consistency  of  the  epiphyseal 
end  was  soft.  The  skiagraph  failed  to  show  the  evidence  of  bone 
tissue,  only  one  small  remnant  being  left  at  the  outer  aspect  of 
the  radius.     Resection  was  advised  first,  but  before  the  patient 


Fig.  218. — Osteosarcoma  of  Right  Arm. 
(Bee  Fig.  219.) 


'I 


Fig.  219. — Skiagraph  of  Arm  Illustrated  by  Fig.  218. 


Fig.  220. — Myelogenous  Osteosarcoma  of  Lower  End  of  Radius. 
(Compare  Fig  221.) 


X  KOI 'LAS  US 


289 


could  make  up  her  mind,  another  month  elapsed,  during  which 
time  the  neoplasm  had  grown  to  the  extent  illustrated  by  Fig.  221. 
In  spite  of  the  extensive  propagation  resection  could  still  be  done. 
No  recurrence  had  been  reported  eighteen  months  after  the  oper- 
ation. 

Fig.  222  shows  osteosarcoma  proper  in  a  woman  of  forty  years. 
The  destruction  of  the  lower  third  of  the  radius  and  of  a  large 
portion  of  the  carpus  is  seen.  Resection  was  performed  more  than 
four  years  ago.  The  perfect  result  was  illustrated  by  a  later  skia- 
graph, which  showed  a  slight  and  most  uniform  atrophy  of  the 


Fig.  221. — Myelogenous  Osteosarcoma  of  Lower  End  of  Radius. 
(Compare  Fig.  220.) 

whole  left  hand.  In  a  third  skiagraph,  which  was  taken  four 
years  after  the  operation,  the  regeneration  of  the  osseous  tissue 
can  be  well  studied. 

Fig.  223  illustrates  the  same  type  in  a  woman  of  twenty-nine 
years.  A  conservative  operation  was  proposed  a  year  ago.  So  far 
no  recurrence  is  observed. 

The  hard  myelogenous  variety,  generally  called  endosteal  or 
central  sarcoma,  also  shows  the  ordinary  sarcomatous  structure. 
But  its  distinguishing  feature  is  its  fibrous  texture  and  the  pres- 
ence of  spindle  cells.  Some  portions  contain  various  tissues,  the 
spindle-cell  tissue  often  containing  giant  cells.  If  smaller  or 
20 


Fig.  222. — Osteosarcoma  of  Radius. 


Fig.  223.— Osteosarcoma  of  Eadius. 


NEOPLASMS 


291 


larger  bone  trabecule  are  produced,  it  is  called  osteosarcoma 
proper;  if  there  are  calcareous  deposits,  petrifying  sarcoma.  If 
the  tissues  become  vascular,  telangiectatic  sarcoma  will  develop, 
which  may  be  mistaken  for  an  aneurysm.  In  later  stages,  when 
there  is  a  regressive  metamorphosis,  fatty  or  cystic  degeneration 
may  take  place.  Then  neoplasms,  which  occur  especially  in  the 
femur,  tibia,  and  inferior  maxilla,  may  attain  an  enormous  size. 
The  skiagraph  of  osteosarcoma  proper  shows  more  osseous  tissue 


Pig.  224. — Osteosarcoma  of  Femuk. 


than  the  periosteal  variety,  but  its  outlines   are  very  irregular. 
They  usually  commence  near  the  epiphysis  of  a  long  bone. 

Fig.  224  illustrates  the  cystic  osteosarcoma  of  the  femur  in 
a  man  of  forty-eight  years.  The  first  signs  of  the  swelling  were 
observed  three  months  before  the  skiagraph  was  taken,  but  there 
were  vague  symptoms,  especially  pain  in  this  region  and  disturb- 
ance of  function,  about  nine  months  before  that  time,  which 
were  interpreted  as  muscular  rheumatism.  Inspection  and  palpa- 
tion revealed  the  presence  of  a  cyst,  filled  to  half  of  its  extent 
with  serum,  the  microscopical  examination  of  which  proved  to  be 
negative.     The  skiagraph  revealed  the  presence  of  bone-prolifera- 


292 


THE    EONTGEX    EAYS 


tion  around  the  whole  circumference  of  the  middle  of  the  femur, 
surrounded  by  a  very  light  area.  The  latter  indicated  the  cystic 
fluid.     The  knowledge  that  the  sarcoma  was   of  a  myelogenous 


Fig.  2:25. — Lakge  Lipoma  of  Thigh. 


nature  induced  the  author  to  make  an  attempt  to  resect  the  sar- 
comatous area,  in  which  he  succeeded  so  far,  as  no  recurrence 
was   observed   a   year   after    operation.     Further   observation,   of 


N  KOI' LA  SMS 


203 


course,  must  show  whether  amputation  caD  finally  be  avoided. 
The  microscope  demonstrated  the  presence  of  giant  cells. 

To  illustrate  the  value  of  the  rays  in  differentiation,  Fig.  225 
may  serve  as  a  counterpart.  Ii  concerns  a  lady  of  forty-nine  years 
who  noticed  a  slowly  growing  tumour  in  her  thigh.  When  the 
author  examined  her,  a  globular  tumour  of  a  sofl  consistency  was 
found  to  occupy  the  larger  half  of  the  thigh.  Some  portions  ap- 
peared to  be  fibrous,  while 
others  showed  pseudofluctua- 
tion.  The  history,  especially 
the  painless  onset  and  the 
location,  gave  the  author  the 
impression  that  a  malignant 
growth,  perhaps  a  cystosar- 
coma,  was  developing.  As- 
piration was  suggested,  but 
the  patient,  whose  domicile 
was  at  a  great  distance  from 
New  York,  gave  the  author 
no  chance  for  this  procedure. 
A  skiagraph,  however,  was 
obtained  which  proved  two 
points  at  least.  In  the  first 
place  the  integrity  of  the  bone 
was  evident,  thus  excluding 
osteosarcoma ;  and  secondly 
the  shadow  of  the  tumour  was 
so  regular,  and  so  opaque,  in 
contradistinction  to  the  light 
cystic  area  of  the  case  illus- 
trated by  Fig.  224,  that  a  solid 

tumour,  independent  from  the  bone,  had  to  be  assumed.  The 
operation  revealed  the  presence  of  a  large  lipoma,  as  the  author 
learned  later  on  by  the  courtesy  of  the  surgeon  who  removed  it. 

The  alveolar  variety  is  characterized  by  its  alveolar  stroma, 
which  contains  nests  of  large  cells.  This  form  has  a  predilection 
for  the  bones  of  the  skull  and  the  trunk. 

The  multiple  variety  (so-called  myeloma),  characterized  by 
the  presence  of  numerous  whitish  foci,  consists  of  small  round 
cells.     It  has  the  same  structure  as  the  lymphoid  sarcoma.     It  is 


Fig.   226.— Sarcoma  of  Superior  Max- 
illa Extending  to  the  Os   Frontis. 


294 


THE    KONTGEN    RAYS 


nearly  exclusively  found  in  very  old  individuals,  for  whose  skull 
and  trunk  it  shows  the  same  predilection  as  the  former  variety. 

The  skiagraph  of  the  alveolar  as  well  as  that  of  the  multiple 
type  shows  the  foci  as  light  irregular  shadows.  Their  structure, 
their  manner  of  destroying  the  pre-existing  bone  tissue,  their 
thin  osseous  walls,  and  their  trabecular  formation  furnish  the 
stand-point  for  their  skiagraphic  study.  Osteoporosis  of  the  trabe- 
ulse  means  decalcification  of  the  bony  portion  affected,  which  ex- 
plains their  foggy  shad- 
ows. Intraosseous  tension 
is  responsible  for  the  ex- 
pansion of  the  compact 
osseous  layer,  which  is 
thus  made  gradually 
weaker,  and  at  last  almost 
entirely  disappears.  Thus 
we  see  that  it  is  the  ab- 
normal and  indefinite  out- 
line or  even  the  entire  ab- 
sence of  the  osseous  cells, 
the  cortex  especially  dis- 
appearing, which  is  more 
or  less  characteristic  of 
the  various  types  of  osse- 
ous sarcoma  in  contra- 
distinction to  other  bone 
diseases. 

Fig.    226    shows   skia- 
graph    of     alveolar     sar- 
coma of  superior  maxilla 
and  os  frontis. 
In  chronic  osteoperiostitis  the  walls  appear  irregular,  too,  but 
the  irregularity  is  one-sided,  and  there  is  a  globular  or  spindle 
shape.     In  tuberculosis  the  shadow  would  be  cloudy  or  shaggy. 
In  osteomyelitis  the  cortex  shows  nearly  normal  outlines. 


Fig.  227.— Osteoma  of  Humerus. 


Osteoma,  of  course,  shows  the  shape  of  the  osseous  deformity, 
but  there  is  the  normal  architectonic  structure.  Fig.  227  illustrates 
osteoma  at  the  outer  aspect  of  the  upper  third  of  the  humerus  in 
a  boy  of  five  years.     His  history  showed  that  there  was  a  fall  more 


NEOPLASMS 


205 


Fig.  228. — Multiple  Exostoses  (Humerus,  Scapula  and  Ribs). 


than  a  year  before  the  development  of  the  bony  projection.  The  nor- 
mal osseous  structure,  as  it  was  evident  from  the  skiagraph,  proved 
the  absence  of  a  malignant  growth.     The  same  applies  to  exostosis. 

Fig.  228  illustrates  multiple 
exostosis  in  a  boy  of  five  years 
who  is  perfectly  normal  other- 
wise. 

In  chondroma  there  is  a  regu- 
lar light-shade  area  in  accord- 
ance with  its  cartilaginous  char- 
acter. 

Fig.  229,  for  instance,  illus- 
trates a  chondroma  at  the  outer 
aspect  of  the  first  phalanx  of 
the  middle  finger.  The  micro- 
scopical examination  made  after 
the  removal  of  the  tumour  cor- 
roborated the  correctness  of  the 

skiagraph  (Fig.  230). 

°.  '       i  ,-,  Fig.  229.— Osteoma  of  Finger. 

iig.  231  shows  the  remnant  (See  Fig  930) 


Fig.  230. — Chondroma  of  First  Phalanx  of  Middle  Finger.     (See  Fig.  229.) 


Fig.  231.— Fibroma  of  Fourth  Finger. 


NEOPLASMS 


297 


of  a  small  fibromatosis  growth  at  the  outer  aspect  of  the  second  pha- 
langeal joint  of  the  fourth  phalanx.  The  growth  was  believed  to 
be  a  simple  wart,  therefore  it  was  cut  off  Hush  with  the  skin  and 
cauterized.  But  the  wound  did  not  heal.  The  skiagraph  of  course 
suggested  extirpation  of  the  remaining  portion  of  the  fibroma. 

In  acromegaly  the  phalanges  of  the  hand  are  broader  than 
normal,  and  show  no  osteophytes,  while  their  epiphyseal  cn<\*  arc 
thickened,  the  long  bones  appearing  straighter  and  broader  than 


Fig   232. — Foot  in  Acromegaly. 

normal  (Fig.  232).  Some  of  the  carpal  as  well  as  tarsal  bones 
are  distinguished  by  the  presence  of  exostoses. 

Similar  osseous  and  articular  changes  are  found  in  the  so- 
called  osteoarthropathie  hypertrophiante  pneumique. 

In  myxcedema  the  epiphyseal  lines  of  the  long  bones  are  hyper- 
trophied  and  show  rich  osseous  proliferations,  which,  however,  con- 
tain but  few  calcareous  salts. 

In  the  obscure  vaso-motoric  lesion,  called  Raynaud's  disease. 
the  nutrition  of  the  bones  is  also  disturbed,  slight  proliferations 
and  rarefaction  being  observed  by  the  author.  (See  Eeport  of 
Literature. ) 


298  THE    EONTGEN    RAYS 


OSSEOUS    CYSTS 

Cysts  of  the  long  bones  are  of  a  decidedly  benign  character, 
and  consequently  they  are  accessible  to  conservative  surgical 
treatment.  But,  unfortunately,  their  signs  resemble  those  of 
osteosarcoma  so  much  that  the  temptation  to  treat  them  alike  is 
not  small.  In  view  of  its  malignant  character,  osteosarcoma  justi- 
fies the  most  radical  steps,  while  osseous  cysts  demand  simple 
opening  and  emptying  of  the  cavity. 

The  grave  prognosis  of  sarcoma  arms  the  surgeon  against  any 
feeling  of  sentimentality.  Under  the  circumstances  he  will  not 
shrink  from  urgently  advising  one  of  the  most  multilating  oper- 
ations, because  he  knows  that  otherwise  not  only  a  limb,  but  also 
life  will  be  lost. 

On  the  other  hand,  how  painful  must  it  be  for  a  surgeon  to 
find  that  because  of  his  error  of  diagnosis  such  radical  steps  have 
been  taken  unnecessarily;  that,  in  other  words,  an  extremity  was 
amputated  where  only  an  osseous  cyst  existed,  which  could  have 
been  cured  by  simple  incision. 

Indeed,  it  is  not  very  difficult  to  confound  the  two  diseases. 
Osseous  cyst  resembles  osteosarcoma  in  its  slow  and  painless 
onset,  often  preceded  by  an  injury,  in  the  gradual  bulging  of  the 
area  involved,  and  in  its  preference  for  youthful  age.  The  differen- 
tial diagnosis  therefore  can  neither  be  made  by  simply  considering 
the  history,  nor  by  inspection,  nor  by  palpation. 

The  fact  that  the  interior  of  the  cyst  is  filled  with  opaque 
bloody  serum,  and  that  its  walls  are  lined  with  a  smooth  coat, 
while  in  osteosarcoma  solid  masses  are  formed,  indicates  that  an 
exploratory  incision  combined  with  microscopical  examination 
would  clear  the  question  of  diagnosis. 

But  here,  also,  as  in  many  other  obscure  ailments,  the  Bontgen 
rays  have  shown  their  usefulness.  Not  only  do  they  differentiate 
well,  but  they  even  give  us  more  valuable  information  than  the 
exploratory  incision  itself,  which,  therefore,  should  always  be  pre- 
ceded by  skiagraphic  examination;  and  for  the  patient  a  skia- 
graphy exposure  is  certainly  more  agreeable  than  an  exploratory 
operation.  After  a  conservative  operation  has  been  decided  upon 
the  microscopical  examination  may  well  be  made  after  the  oper- 
ation. 


NEOPLASMS  299 

From  a  skiagraphic  study  of  107  cases  of  osteosarcomas,  the 
writer  feels  justified  in  saying  that  in  osteosarcoma  the  outlines 
of  the  bone  always  appear  more  or  less  abnormal  and  indefinite, 
some  areas  even  appearing  entirely  translucent;  while  in  osseous 
cyst  the  cortex  appears  thin  and  narrow,  but  well  marked  and 
regular.  The  fluid  centre  of  the  bone  is  entirely  translucent,  the 
light  shadow  showing  the  same  regularity.  The  adjacent  epiphyses 
are  normal.  Only  in  the  rare  event  of  cystic  degeneration  at  the 
upper  epiphysis  of  the  femur  it  must  be  considered  that  the  regu- 
larity of  the  translucent  (cystic)  area  is  somewhat  impaired  by  the 
anatomical  peculiarities  of  the  trochanter  major. 

It  is  especially  the  regularity  of  the  texture  of  the  walls  of 
the  cavity  as  they  appear  on  the  skiagraph  which  seem  to  be  the 
characteristic  skiagraphic  features  of  osseous  cyst  in  contradis- 
tinction to  the  irregular  texture  of  osteosarcoma.  It  may  be  added 
that  the  vicinity  of  the  epiphysis  is  also  in  favour  of  osseous  cyst 
for  histological  reasons,  as  will  be  explained  below. 

The  following  cases  may  serve  as  a  practical  illustration  of 
the  value  of  the  Eontgen  rays  in  differentiation : 

Case  I,  presented  to  the  surgical  section  of  the  Academy  of 
Medicine,  March  11,  1901.  H.  C,  a  well-nourished  boy,  aged  ten 
years,  emigrated  from  Eussia  several  months  ago  and  presented 
himself  on  November  18,  1900.  His  family  history  is  good.  He 
was  always  well  until  eleven  months  ago,  when  he  fell  into  an  ex- 
cavation on  the  street.  On  account  of  the  intense  pain  in  the 
upper  portion  of  his  right  tibia  and  the  functional  disability  a 
fracture  was  thought  of  at  first,  but  after  having  remained  in  bed 
for  two  days  he  was  able  to  walk  around  again.  Four  weeks  later 
he  fell  again  on  the  street,  showing  the  same  symptoms  as  on  the 
previous  accident,  but  this  time  he  had  to  stay  in  bed  for  four 
weeks.  It  was  then  that  a  swelling  of  the  size  of  a  large  filbert  was 
detected  at  the  spine  of  the  right  tibia. 

Three  months  before  the  demonstration  he  fell  for  the  third 
time,  then  being  confined  in  bed  for  six  weeks.  When  he  got  up 
he  was  free  from  pain,  but  he  limped,  and  the  swelling  below  his 
right  knee  had  increased  markedly.  Walking  had  become  more 
and  more  difficult. 

The  mother  reported  that  she  had  sought  surgical  advice  and 
that  the  tumour  had  been  pronounced  to  be  a  malignant  growth, 
which  demanded  immediate  operation  to  save  the  boy's  life. 


300 


THE    RONTGEN    RAYS 


Inspection  revealed  a  normal  and  freely  movable  knee-joint. 
Nearly  the  whole  upper  half  of  the  tibia  was  occupied  by  a  painless 
swelling,  which  had  the  shape  of  a  spindle,  and  was  most  pro- 
nounced anteriorly.  It  began  at  the  epiphyseal  line,  reached  its 
height  at  the  upper  third  of  the  tibia,  and  merged  gradually  into 
the  normal  features  of  the  tibia  at  its  middle.  The  fibula  ap- 
peared to  be  entirely  normal.  The  circumference  of  the  leg  at  the 
most  prominent  point  was  30  centimetres,  while  that  of  the  left 

leg  measured  25  centi- 
metres. The  surface 
of  the  tumour  was 
smooth.  Its  consist- 
ency was  hard;  a  few 
areas  appeared  slightly 
softer.  Forcible  press- 
ure revealed  the  pres- 
ence of  oedema.  There 
was  neither  pulsation 
nor  fluctuation.  The 
skin  was  normal  and 
movable.  The  inguinal 
region  did  not  show 
the  presence  of  swollen 
glands. 

It  was  no  more 
than  natural,  in  view 
of  these  facts,  to  think 
that  an  osteosarcoma 
had  to  be  dealt  with; 
but  before  arriving  at 
a  definite  conclusion  the  writer  consulted  the  Rontgen  rays,  which 
revealed  the  presence  of  a  large  triangular  shape,  the  base  of 
which  corresponded  to  the  epiphyseal  line.  The  triangle  was  sur- 
rounded by  a  narrow  dark  and  regularly  arranged  shadow,  which 
represented  the  distended  but  otherwise  normal  cortex  of  the  tibia. 
The  light  shadow  was  interpreted  as  a  cavity,  presumably  contain- 
ing a  fluid  of  some  kind.  The  normal  outlines  of  the  fibula 
could  be  distinctly  recognised  through  the  light  area,  although 
the  inner  surface  of  the  leg  rested  on  the  photographic  plate 
(Fig.  233). 


Pig.  233.— Osseous  Cyst  of  Tibia. 


NEOPLASMS  301 

The  marked  regularity  of  the  texture  of  the  cortex,  as  well  as 
the  uniformity  of  the  light  shadow  representing  the  cavity,  con- 
vinced the  writer  that  osteosarcoma  was  not  present  in  this  case, 
therefore  he  advised  conservative  operation.  This  was  performed 
at  St.  Mark's  Hospital,  November  21,  1900. 

The  anterior  surface  of  the  tumour  was  first  exposed.  After 
having  incised  the  thin  hone  shell  with  a  hone-knife  bloody  serum 
escaped  through  the  opening  made.  Now  an  elliptic  portion  was 
removed  from  the  osseous  shell  in  order  to  get  access  to  the  large 
cavity,  which  was  filled  with  black,  bloody,  viscid  serum.  There 
were  no  coagula.  The  osseous  walls  were  lined  with  a  thin  mem- 
brane, and  the  cavity  was  traversed  by  a  few  fibres  of  osseous  rem- 
nants, arranged  like  network,  but  not  much  thicker  than  a  thread. 

After  having  scooped  out  the  cavity  thoroughly  its  osseous 
wall  were  so  thin  that  by  pressing  them  together  forcibly — in- 
fracturing  them,  in  fact — their  inner  surfaces  could  be  well  ap- 
proximated, so  that  no  more  cavity  existed,  so  to  say.  Instead 
of  packing  the  cavity,  the  writer  preferred  to  resort  to  this  unusual 
procedure,  analogous  to  the  principles  of  approximation  of  the 
chest-wall  in  old  pyothorax.  Only  in  the  lower  edge  of  the  bone 
wound  a  small  iodoform  wick  was  introduced.  There  was  con- 
siderable bloody  oozing  until  live  days  after  the  operation,  when 
the  secretion  became  serous.  Recovery  was  uninterrupted.  Only 
a  small  sinus,  discharging  a  few  drops  of  serum  in  a  day,  is  still 
present.  The  patient  has  now  been  up  for  two  weeks  and  walks 
well.  The  repair  was  also  well  illustrated  by  a  skiagraph  taken 
two  months  after  operation.  At  the  present  writing  the  patient  is 
well.  The  microscopical  examination  of  the  exsected  bone-frag- 
ment and  its  membrane,  made  by  the  courtesy  of  Prof.  Henry 
T.  Brooks,  showed  the  presence  of  many  round  cells,  espceially 
around  the  blood-vessels.  There  was  no  epithelial  stratum  nor  any 
evidence  of  bacteria. 

Case  II. — E.  T.,  a  girl,  aged  thirteen  years,  born  in  New  York 
city,  presented  herself  to  the  writer  on  April  4,  1899.  Eight 
months  ago  she  slipped  on  a  stairway  and  was  unable  to  stand 
on  her  feet  again.  The  left  ankle  became  swollen  and  painful. 
Fomentations  were  applied  for  several  weeks.  No  medical  advice 
was  sought  until  the  swelling,  which,  after  four  weeks'  rest,  had 
become  painless,  increased. 

The  family  history  of  the  patient  was  good.     Inspection  re- 


302  THE    EONTGEK    EAYS 

vealed  a  movable  ankle-joint.  The  lower  third  of  the  tibia  was 
occupied  by  a  painless  tumour,  which  appears  like  exuberant  callus 
formation.  The  external  malleolus  is  normal.  The  circumference 
of  the  leg  at  the  most  prominent  point  is  22  centimetres,  while 
that  of  the  right  leg  measures  18  centimetres.  The  surface  of  the 
tumour  is  smooth;  the  consistency  is  hard.  A  skiagraph  taken  at 
once  revealed  the  same  condition  present  in  Case  I,  with  the  dif- 
ference that  the  shadow  of  the  cortex  is  somewhat  larger.  (The 
American  Journal  of  the  Medical  Sciences,  June,  1901.) 

The  operation  was  the  same  as  in  Case  I.  The  cavity  contained 
the  same  black,  viscid  serum;  the  walls  of  the  cavity,  however, 
were  thicker  than  those  of  Case  I,  and  to  their  inner  surface  a 
stratum  of  grayish-white  tissue  was  attached.  It  had  the  appear- 
ance of  enchondromatous  masses  and  proved  to  consist  of  carti- 
laginous tissue.  The  microscopical  examination  revealed  an 
abundance  of  nuclei,  especially  of  round  cells,  surrounded  by 
myxomatous  and  disintegrated  tissue.  The  walls  could  not  be  ap- 
proximated as  well  as  in  Case  I  by  forcible  compression.  The 
remainder  of  the  cavity,  therefore,  was  packed  with  iodoform 
gauze.  Eecovery  was  perfect  after  four  and  a  half  months.  The 
patient  has  remained  well  ever  since. 

The  setiology  of  osseous  cysts  is  still  sub  judice.  Virchow  1 
maintains  that  all  osseous  cysts  are  the  softened  products  of  de- 
generation of  such  growths  that  were  solid  formerly.  Such  solid 
tumours  should  have  originated  from  erratic  cartilaginous  frag- 
ments left  from  the  epiphyseal  line. 

Schlange,  according  to  his  excellent  monograph,  observed  car- 
tilaginous fragments  in  the  tissues  of  the  cyst-wall.  Similar  obser- 
vations were  made  by  Franz  Koenig,  by  Deetz,  and  Koch. 

At  the  early  stage  osseous  cysts,  be  they  in  the  tibia  or  in 
the  femur,  are  easily  overlooked,  the  symptoms  being  insignificant. 
Sometimes  there  is  very  slight  intermittent  pain.  The  joints  are 
freely  movable,  and  neither  inspection  nor  palpation  reveal  any 
abnormality.  After  months  the  circumference  of  the  extremity 
may  appear  very  slightly  enlarged,  but  the  symptoms  may  not  be 
fully  appreciated  until  a  fall  on  the  thin  shell  of  the  cortex  pro- 
duces a  fracture.  Whether  in  our  cases  fracture  had  occurred 
could  not  be  elicited.     Eelying  upon  the  Eontgen  rays,  the  writer 

1  Virchow  :  TJeber  Bildung  von  Knochencysten,  Monatsbericht  der  Berliner 
Akademie  der  Wissensehaften.     Mathematisch-physikalische  Klasse,  1876. 


NEOPLASMS  303 

was  inclined  to  believe  that  the  previous  injuries  had  the  charac- 
ter of  severe  contusions,  in  view  of  the  difficulty  of  differentiating 
between  a  benign  cyst,  accessible  to  conservative  surgery,  and  osteo- 
sarcoma, demanding  the  most  radical  measures,  the  writer  advocates 
exposing  all  osseous  growths  to  the  Rontgen  rays  before  passing 
a  final  judgment  in  a  matter  of  such  grave  importance. 

Case  III. — A  girl  of  eleven,  born  in  Germany  of  weakly 
parents,  noticed  a  diminutive  swelling  on  the  upper  third  of  the 
tibia  about  a  year  ago,  shortly  after  a  heavy  substance  had  fallen 
on  the  leg.  It  caused  her  no  pain  at  the  time.  But  as  the  swelling 
increased  considerably  in  size,  a  dull  pain  with  some  loss  of  func- 
tion set  in.  The  patellar  reflex  was  exaggerated.  The  region  of 
the  swelling  is  painful  on  pressure.  The  swelling  can  be  indented 
and  a  crackling  sound  can  be  heard. 

The  patient  shows  evidence  of  enlarged  glands  in  the  neck, 
and  adenoid  growths  in  the  nasopharynx.  When  a  child  she  had 
measles  and  scarlet  fever. 

The  Rontgen  picture  shows  a  regular  and  sharply  outlined 
cortical  line  of  the  thickness  of  a  playing  card.  It  represents  the 
boundary  of  a  transparent  oval  space  and  spindle-shaped  form. 
The  cohesion  of  the  sheath  is  not  severed  at  any  point.  The 
epiphyses  are  normal. 

The  diagnosis  of  osseous  cyst  was  made  accordingly,  and  an 
incision  made  at  St.  Mark's  Hospital.  The  diagnosis  was  verified 
by  the  operation. 

The  smooth  walls  of  the  cavity,  which  was  about  the  size  of 
an  apple,  were  lined  with  connective  tissue.  The  contents  con- 
sisted of  a  thin,  sanguineous  fluid.  The  microscopical  examination 
of  the  cyst-wall,  composed  of  several  lamellae,  showed  trabecular 
of  bone  as  well  as  marrow  substance  transformed  into  fibrous 
tissue.  In  between  granulation  tissue  was  found,  as  was  the  case 
in  the  other  specimens.  Around  the  blood-vessels  many  round 
cells  and  large  polynuclear  cells  were  found.  As  in  the  other  cases 
an  epithelium  stratum  was  not  found. 

The  walls  of  the  cavity  were  approximated  by  strong  com- 
pression, which  allows  to  diminish  the  size  of  the  cavity  percep- 
tibly. A  knife-point  of  granular  iodoform  is  dropped  into  the 
depth  of  the  cavity  and  wicks  of  iodoform  gauze  are  placed  in  the 
upper  and  lower  wound  margins.  Recovery  was  perfect  in  three 
months. 


304  THE    RONTGEN"    RAYS 

Case  IV. — The  same  conditions  were  found  in  the  head  of 
the  humerus  of  a  Russian  girl  of  nineteen  years,  who  gave  a  his- 
tory of  an  injury  there  which  was  treated  for  fracture  during  five 
months  until  the  rays  revealed  the  nature  of  the  swelling  of  her 
shoulder.     The  cystyc  area  was  of  globular  shape. 

The  literature  on  osseous  cysts  is  still  very  scant.  It  is  to  be 
hoped,  though,  that  with  the  ever-increasing  interest  and  recogni- 
tion of  the  Rontgen-ray  diagnosis  the  number  of  the  cases  observed 
will  grow  larger  and  larger,  so  that  we  may  look  forward  to  a  solu- 
tion of  the  question  of  aetiology.  As  yet  it  is  still  sub  judice. 
Virchow's  idea  that  osseous  cysts  are  the  softened  product  of  the 
degeneration  of  tumours  cannot  be  upheld  in  the  light  of  clinical 
experience.  It  is  true  that  cystic  degeneration  may  take  place  in 
myxoma,  fibroma,  nryxofibroma,  osteofibroma,  chondroma,  and 
sarcoma.  Even  multilocular  cysts  may  arise  from  the  degenera- 
tion of  large  sarcomata.  They  show  a  malignant  character,  how- 
ever, their  anamnesis  is  different,  and  the  Rontgen  picture  shows, 
an  irregular  shape,  which  is  due  to  the  fact  that  the  ensheathing 
walls  consist  not  only  of  tumourous  or  connective,  but  also  of 
bone  tissue.  Again,  the  true  osseous  cyst  is  a  disease  of  the  period 
of  development.  The  author  looks  upon  them  as  the  product  of  an 
inflammatory  atrophy,  which  bears  relation  to  the  rarefying  dis- 
eases as  represented  by  osteomalacia,  and  especially  rhachitis.  Sim- 
ilar to  the  latter  the  osseous  cyst  denotes  a  disturbance  of  nutri- 
tion which  is  characterized  by  an  increased  absorption  of  bone, 
finally  leading  to  a  disappearance  of  a  part  of  the  bone  tissue. 
That  portion  of  the  bone  cortex  which  lies  nearest  the  periosteum 
resists  the  absorption  of  the  calcium  salts  the  longest,  and  this  is 
the  explanation  of  the  very  thin,  but  still  plainly  visible  bone-line 
on  the  Rontgen  picture.  The  spongeous  portion  which  lies  nearest 
the  epiphyseal  cartilage  forms  the  seat  of  cartilaginous  deposits, 
which  show  a  decided  tendency  to  spread.  Any  irritation,  espe- 
cially trauma,  will  increase  this  tendency,  and  an  inflammatory 
atrophy  sets  in.  It  resembles  that  which  we  see  following  phleg- 
monous or  arthritic  processes  or  extensive  fractures.  Gradually  the 
bony  structure  of  the  spongiosa  disappears  until  only  a  few  lamellae 
are  left. 

Not  only  the  age,  but  also  the  unexceptional  preference  of  the 
osseous  cysts  for  the  epiphyseal  region,  speak  in  favour  of  the 
relationship  with  rhachitis.    Another  striking  factor  is  that  all  of 


NEOPLASMS  305 

the  author's  cases  have  been  born  in  regions  in  which  rhachitis 
is  endemic. 

Some  one  may  criticise  that  the  author  is  not  justified  in  draw- 
ing up  general  diagnostic  rules,  having  only  tour  cases  to  fall  back 
upon.  But  to  this  is  to  he  responded  in  advance  that  for  the  last 
seven  years  it  has  been  customary  in  the  writer's  three  clinic-  to 
skiagraph  every  bone  affection.  Owing  to  the  courtesy  of  his  pro- 
fessional friends  the  author  was  able  to  represent  L01  cases  of 
osteosarcoma  up  to  the  present  time.  These  cases  were  studied 
thoroughly,  and  as  the  majority  was  operated  upon,  the  micro- 
scopical diagnosis  could  he  added  in  most  cases.  In  none  of  these 
cases  were  these  three  found  : 

Eegularity  of  the  thin  cortex,  parallel  with  the  oval,  spindle- 
shaped  or  trianguar  transparency  of  the  distended  cavity.  Of 
course  there  are  some  cases  among  these  which  simulate  the  typical 
osseous  cyst,  but  on  closer  examination  we  find  an  insufficient 
transparency  or  severing  of  the  cortical  line.  The  author  regards 
himself  justified,  therefore,  to  impress  the  importance  of  these 
points  of  differential  diagnosis  upon  his  colleagues. 

Tubes  of  medium  hardness  must  be  used.  If  hard  tubes  are 
selected  the  thin  cortex  becomes  transparent  also,  and  the  same 
conditions  as  in  osteosarcoma  may  be  produced  on  the  plate. 


21 


CHAPTER    XV 
UTILIZATION  OF  THE  RON  TO  EN  RAYS  IN  FRACTURES 

As  is  well  known,  the  first  object  of  a  rational  therapy  of  all 
fractures  is  the  consolidation  of  the  fractured  ends  without  any 
displacement  and  without  injuring  the  adjacent  tissues,  or  the 
function  of  the  limb.  It  is  evident  that  if  there  is  no  displace- 
ment no  replacement  (or,  better  said,  reposition)  will  be  neces- 
sary. All  that  is  then  required  is  to  protect  the  injured  limb  in  its 
normal  position.     This  is  done  by  proper  immobilization. 

In  the  great  majority  of  cases,  however,  more  or  less  displace- 
ment follows  the  fracture.  In  such  an  event,  of  course,  the  dis- 
placed fragments  must  be  reduced  to  their  normal  position. 
After  exact  reposition  has  been  attained,  proper  fixation  in  the 
normal  position  is  in  order.  These  doctrines  are  so  simple  that  it 
seems  almost  unnecessary  to  repeat  them.  Yet  they  are  frequently 
violated.  The  functional  impairment  following  non-reduced  frac- 
tures, especially  the  formation  of  adhesions,  has  led  a  number  of 
surgeons  to  enunciate  the  dogma  that  the  treatment  of  the  soft 
tissues  is  the  most  important  part  in  the  treatment  of  fracture. 
They  claim,  in  other  words,  that  because  the  function  of  the  soft 
tissues,  for  instance,  of  the  tendons,  is  impaired  after  an  unre- 
duced fracture,  the  soft  tissues  should  have  received  more  atten- 
tion, instead  of  the  displaced  fragment  having  simply  been  reduced 
to  where  it  belongs.  Nothing,  in  fact,  is  more  contrary  to  com- 
mon sense  than  this  dangerous  maxim,  which  is  partially  based 
upon  correct  observation,  but  entirely  upon  incorrect  interpreta- 
tion. It  should  always  be  considered  that  the  relations  of  the  soft 
tissues  to  the  bones  are  like  those  of  the  clinging  vine  to  the 
sturdy  oak. 

Galen  says  that  the  bones  give  the  human  body  form,  erect- 
ness,  and  firmness.  It  is  evident  that  an  injury  of  the  bones  im- 
pairs these  three  fundamental  factors.  The  most  important  step 
towards  repair  must  thus  be  taken  in  the  foundations  rather  than 
in  the  superimposed  structures. 
306 


THE    RONTGEN    RAYS  IX   FRACTURES  307 

If  there  is  displacement  of  the  hone  fragments,  undue  pressure 
must  necessarily  be  made  upon  the  soft  tissue ;  non-reduction 
means  persistence  of  pressure,  the  fatal  consequences  of  which  are 
well  known.  Reduction  means  the  relief  of  pressure.  If  in  the 
frequent  fracture  of  the  carpal  end  of  the  radius  the  lower  frag- 
ment is  displaced  upward  (compare  Fig.  348)  the  extensors  are 
unduly  stretched,  as  they  are  upheld  like  the  strings  of  a  violin  by 
the  bridge.  Of  course,  the  act  of  injury  to  the  soft  tissues  can- 
not be  undone  by  the  mere  cessation  of  pressure — that  is.  by  re- 
duction— but  the  influence  of  the  injury  on  the  soft  tissues — the 
influence  of  the  pressure,  in  fact — lasts  only  a  short  time,  and  is 
insignificant  after  early  reduction,  and  therefore  repair  is  easy. 
This  means  that  the  main  premise  of  adhesion — formation,  is 
wanting.  And  clinical  observation  shows  that  with  perfect  reposi- 
tion the  joints  as  well  as  the  sheaths  of  the  tendons  are  found 
free,  provided  the  immobilization  has  not  lasted  for  an  extraordi- 
nary length  of  time. 

A  fracture  is  a  solution  in  the  continuity  of  the  bone,  just  as  a 
wound  is  a  solution  in  the  continuity  of  the  tissues  in  general. 
The  aim  of  modern  wound  treatment  is  union  by  first  intention. 
The  most  important  requirement  for  this  end  is,  besides  aseptic 
precautions,  the  thorough  adaptation  of  the  wound  surfaces. 

No  surgeon  would  expect  agglutination  if  there  be  displace- 
ment, diastasis,  or  overlapping  of  the  wound  margins.  The  same 
principle  applies  to  the  treatment  of  the  margins  of  the  bone  frag- 
ments. It  is  true  that  manual  coaptation  is  a  little  more  difficult 
than  suturing;  still,  under  the  guidance  of  the  Kontgen  rays  it 
can  always  be  accomplished  if  there  are  no  extraordinary  circum- 
stances. Before  their  advent  it  was  usually  the  final  result  alone 
which  told  of  the  success  or  failure  of  treatment.  That  result 
was  then  a  fait  accompli,  and  the  time  for  proper  correction  had 
passed. 

Now,  with  our  Rontgen-light  mentor  we  can  tell  from  the  very 
beginning  what  the  result  will  he.  If  the  "  Kontgen  mirror  "  re- 
flects perfect  coaptation  of  the  fragments  underneath  the  dressing, 
the  final  result  must  be  good.  There  will  be  hardly  any  reaction; 
no  exudation  will  form  around  the  agglutinating  surfaces,  and 
consequently  there  will  be  no  adhesions.  Even  in  those  cases  in 
which  considerable  displacement,  or  comminution,  or  both,  have 
injured  the  soft  tissues,   little   reaction   follows   within  therm   if 


308  THE    RONTGEN    RAYS 

reduction  be  thorough.  And  if  reduction  is  impossible,  the  Ront- 
gen  rays  point  to  those  fragments  which  are  to  be  removed  shortly 
after  the  injury.  This  is  preferable  to  waiting  for  months,  ex- 
hausting all  mechanical  means,  and  finally  arriving  at  the  conclu- 
sion that  the  deforming  fragments  had  better  be  removed.  What 
many  of  us  have  in  former  years  regarded  as  a  callus  was  nothing 
but  a  projecting  piece  of  bone-fragment  in  a  displaced  position. 
It  may,  perhaps,  be  a  pardonable  policy  to  adhere  to  this  most 
euphonic  term  in  the  presence  of  the  inquisitive  and  criticising 
patient,  who  has  a  dangerous  desire  of  learning  the  cause  of  his 
gibbous  joint.  But  a  scientific  forum  cannot  ignore  this  frequent 
failure  to  reduce. 

The  regular  scar  of  a  well-united  wound  must  be  the  model  of 
our  therapeutic  efforts.  Direct  union  is  to  be  striven  for.  What 
is  termed  ensheathing  callus-formation  means  union  by  second  in- 
tention; this  is  certainly  undesirable  as  long  as  union  per  primam 
can  be  well  accomplished.  Ensheathing  callus  is  the  compensating 
effort  of  nature  to  overcome  the  unreduced  deformity  and  to 
bridge  over  the  hiatus  made  by  irregular  adaptation. 

In  order  to  accomplish  exact  reposition,  the  degree  and  the 
direction  of  the  displacement,  as  it  is  shown  by  the  Rontgen  rays, 
must  be  first  considered.  It  is  true  that  an  experienced  surgeon 
will  often  guess  right,  but  he  will  never  Tcnoiv,  except  by  his  infalli- 
ble adjunct,  the  Rontgen  rays.  The  only  safe  method  is  the  self- 
control  by  the  Rontgen  rays.  It  may  appear  to  be  unjust  to 
demand  of  the  struggling  practitioner  that  he  should  supply  him- 
self with  an  expensive  Rontgen  apparatus,  but  after  all  there  will 
hardly  be  any  other  choice.  The  public  is  cruel,  and  the  patient's 
interest  concentrates  itself  almost  entirely  in  his  own  welfare. 
These  principles  apply  especially  to  fractures  situated  near  a  joint. 
Contusion  and  distortion  are  sometimes  taken  for  fissure  and 
often  for  non-displaced  fracture,  and  vice  versa,  as  the  symptoms — 
local  pain  and  enlargement — are  common  to  all.  Crepitus  and 
false  motion  are  absent,  and  this  is  not  surprising,  if  there  is 
much  swelling  or  impaction. 

If  the  principles  of  immediate  reduction  are  adhered  to,  the 
"  gibbous  wrist "  will  cease  to  be  counted  among  the  inevitable 
inventory  of  surgical  clinics.  Still,  the  author  is  afraid,  this  is 
a  pious  wish  as  long  as  there  are  surgeons  who  imagine  that  by 
virtue  of  their  own  especially  developed  palpatory  talent  they  can 


THE    RONTGEN    RAYS   IX   FRACTURES  309 

judge  the  details  of  any  fracture  wiilioui  the  aid  of  the  Rbntgen 
rays.  Some  are  willing  to  use  then)  in  "  obscure"  cases,  but  they 
do  not  realize  that  the  cases  which  they  regard  as  "  non-obscure" 
would  appear  in  a  different  light  when  skiagraphed.  In  other 
Avords,  what  they  regard  to  be  a  simple  fracture  often  turns  out  to 
be  a  complicated  condition.  The  paradox  may  be  justified  here, 
that  if  they  would  see  this  complicated  condition  or  the  fractured 
type  in  its  proper  light,  it  would  then  seem  obscure  to  them. 

As  said  above,  if  there  is  no  displacement,  no  effort  of  reposi- 
tion should  he  made.  How  absurd  then  to  subject  the  patient, 
as  is  often  done,  to  painful  procedures.  In  simple  fissure,  union 
may  be  perfect  under  any,  or  even  in  spite  of  any,  form  of  treat- 
ment. If  the  surgeon,  led  by  anatomical  knowledge,  does  practi- 
cally the  same  as  the  quack  does  on  account  of  his  ignorance — 
namely,  leave  the  healing  process  to  nature — the  same  good  result 
may  finally  be  obtained.  The  scientific  treatment  of  fissure  or  non- 
displaced  fracture  in  which  portions  of  the  periosteum  still  main- 
tain slight  cohesion  of  the  fragments,  viz..  slight  immobilization, 
will  not  alter  any  of  its  mechanism,  but  it  will  at  least  have  the 
value  of  a  greater  or  lesser  comfort  for  the  patient ;  and  in  cases 
of  this  kind  we  must  be  warned  against  scientific  nihilism. 


CHAPTER    XVI 

THE  OPERATIVE   TREATMENT    OF   DEFORMED  FRACTURE 
AS  INDICATED  BY   THE  RONTGEN  RAYS 

How  often  reposition  is  imperfect  if  not  controlled  by  the  Ront- 
gen  rays  has  repeatedly  been  shown  in  the  author's  own  cases.  Fig. 
234  shows  fracture  of  the  fibula  in  malposition  through  a  plaster- 
of-Paris  dressing.  The  dressing  was  applied  after  the  reposition 
was  thought  to  have  been  perfect  by  an  excellent  surgeon.  Of 
course  the  dressing  was  removed  again  when  the  surgeon  saw 
his  error.  If  malunion  occurs,  there  are  such  changes  in  the 
direction,  shape,  and  length  of  a  limb,  that  its  function  becomes 
impaired  or  annulled.  Impairment  of  shape  is  generally  not  so 
grave  as  that  of  length,  especially  when  the  lower  extremity  is 
concerned. 

The  projecting  ends  of  fragments,  when  united  in  a  false  posi- 
tion, frequently  produce  irritation  of  the  neighbouring  tissue.  It 
may  be  a  sharp-pointed  fragment,  which,  if  not  reduced  at  once, 
may  put  the  overlying  skin  under  such  extreme  tension  that  grad- 
ual penetration  will  take  place.  This  event,  changing  a  simple 
fracture  into  a  compound  one,  is  favoured  where  bone  surfaces  are 
located  superficially,  as  at  the  tibia  and  the  lower  third  of  the 
radius  and  ulna. 

Or  the  displaced  fragments  may  be  situated  in  the  neighbour- 
hood of  a  joint,  one  riding  upon  the  other,  so  that  extreme  pro- 
trusion of  one  of  the  fragments  is  caused.  This  would  render  the 
motion  of  the  joint  painful  or  even  impossible.  If  the  fragments 
protrude  far,  as  often  happens  when  they  are  in  juxtaposition, 
there  is  compression  of  the  soft  tissues.  A  nerve  passing  over  this 
region  will  then  be  dislocated  or  unduly  stretched,  so  that  atrophy 
or  inflammatory  irritation  may  result.  In  the  latter  instance  neu- 
ritis, in  the  first  paralysis,  may  be  expected.  Among  all  nerves 
the  radial  is  the  one  most  frequently  concerned.  The  author  has 
described  cases  of  this  kind  in  previous  publications  (see  Fig.  142 
310 


TEEATMENT    OF    DEFOEMED    FEACTUEE        311 

and  143,  and  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen, 
Band  v,  Hamburg).  The  axillary  plexus  may  be  injured  in  frac- 
tures of  the  clavicle  followed  by  backward  displacement  and  by 
that  of  the  neck  of  the  humerus;  the  ulna  by  fracture  of  the  ulna 
or  the  lower  end  of  the  humerus;  the  median  nerve  in  compound 
fracture  of  the  humerus  and  radius;  the  tibia]  nerve  after  fracture 
of  the  tibia;  and  the  peroneal  after  fracture  of  femur  and  fibula. 

Up  to  the  present  time  the  correction  of  these  deformities  has 
not  been  frequently  undertaken,  although  the  Eontgen  rays  now 


Fig.    234  — Fracture  of  Tibia  and  Fibula  taken  through  Plaster-of-Paris 

Dressing. 


enable  us  to  make  a  thorough  diagnosis  of  the  anatomical  rela- 
tions of  the  fragments  as  well  as  to  outline  our  operative  steps  in 
advance.  The  author  has  taken  every  opportunity  to  criticise  the 
deplorable  indifference  and  to  emphasize  the  feeling  of  security  the 
surgeon  enjoys  now  while  proceeding  under  the  mentorship  of  the 
skiagraph.  The  direction  of  the  displacement  can  easily  be  ascer- 
tained, and  if  two  or  three  weeks  only  have  elapsed,  the  refracture 
under  ansesthesia  at  the  edge  of  the  table  will  often  suffice  to  cor- 
rect the  malunion. 

Fig.  235  shows  a  case  of  fracture  of  the  surgical  neck  of  the 
humerus,  in  which  the  diaphysis  had  slipped  upward  alongside 
the  head  of  the  humerus,  so  that  union  had  taken  place  in  juxtapo- 


312 


THE    KONTGEN    BAYS 


sition.  Although  five  weeks  had  elapsed,  refracturing  the  frag- 
ments by  bending  them  over  the  edge  of  the  table  was  successful. 
Without  the  guidance  of  the  rays,  which  showed  the  anatomical 


Pig.  235.— Fracture  of  the  Surgical  Neck  of  the  Humerus— Juxtaposition. 


TREATMENT    OF    DEFORMED    FRACTURE        313 

relations  most  clearly,  the  author  would  have  had  neither  the 
courage  nor  the  ability  to  perform  the  correction,  which,  in  fact, 
was  done  easily  enough,  since  it  could  be  estimated  exactly  how  to 
direct  the  force  of  the  manipulations.  In  transverse  fractures  re- 
fracture  may  even  he  tried  months  afterward,  provided  there  is 
axial  displacement  (see  Figs.  33,  34,  35). 

If  such  procedures  fail,  the  only  remedy  consists  in  osteotomy 
in  the  fracture-line.  This  is  especially  indicated  when  the  frag- 
ments are  in  juxtaposition  (Fig.  246).  If  thorough  aseptic  pre- 
cautions are  taken,  tearing  of  the  wound  edges  espei  tally  being 
avoided,  and  the  wound  itself  coming  in  contact  with  the  hands 
of  the  surgeon  as  little  as  possihle,  no  reaction  will  take  place 

In  fracture  of  a  single  bone,  such  as  the  femur  or  humerus,  a 
longitudinal  incision  should,  as  a  rule,  be  made  over  the  most 
prominent  part  of  the  displaced  fragment,  except  it  be  in  the  im- 
mediate neighbourhood  of  a  large  vessel,  which  is  to  be  avoided. 
In  fracture  of  the  femur,  for  instance,  the  exterior  or  posterior 
surface  should  be  preferred. 

In  fracture  of  two  bones  (tibia  and  fibula  or  radius  and  ulna) 
a  semilunar  incision,  preferably  on  the  extensor  surface,  is  recom- 
mended, since  it  exposes  both  bones  simultaneously.  The  peri- 
osteum is  divided  longitudinally  and  shifted  aside  by  the  use  of  a 
periosteal  elevator.  Old  adhesions  are  thoroughly  freed  with  the 
bone  knife,  and  the  united  ends  separated  with  hammer  and  chisel 
(linear  osteotomy).  Then  the  fragments  are  bent,  the  whole  limb 
being  folded,  so  to  speak.  An  assistant  steadies  the  two  folded 
portions  after  they  are  encircled  with  a  strong  bandage,  so  that 
the  bone  ends  can  be  trimmed  properly.  This  can  be  accomplished 
in  various  ways,  the  author's  own  experience  being  in  favour  of 
triangular  indentation.  This  mode  of  procedure  permits  of  a 
most  accurate  adaptation  and  immobilization,  and  seldom  requires 
the  use  of  foreign  bodies  for  fixation.  A  wedge  is  removed  from 
one  end  of  the  fragments,  into  which  the  other  end  is  made  to  fit 
by  the  use  of  a  saw  (preferably  a  wire  saw).  In  bones  presenting 
broad  transverse  surfaces  the  adaptation  may  be  made  still  more 
intimate  by  creating  two  triangular  tips  fitting  into  two  propor- 
tional wedges.  After  the  fragments  are  well  approximated,  the 
periosteal  margins,  as  well  as  the  fascia?,  are  united  separately.  If 
aseptic  precautions,  hasmostasis,  and  coaptation  are  perfect,  no  re- 
action follows.    The  wound  is  simply  protected  by  iodoform  gauze 


314  THE    EONTGEN    EAYS 

and  a  piece  of  moss  board,  and  a  fenestrated  plaster-of-Paris  dress- 
ing is  applied  over  the  wound  dressing.  In  operations  on  the 
femur  such  immobilization  may  be  combined  with  an  extension 


Fig.   236. — Fracture  of    Tibia.  Wired,  and    Double  Fracture  of   Fibula  in 

Mal-union. 

apparatus.  Since  the  Eontgen  rays  permeate  even  the  plaster-of- 
Paris  dressing,  the  immediate  result  of  the  coaptation  is  easily 
studied,  and  modified  if  necessary. 

Approximation  and  fixation  can  also  be  accomplished  by  the 
use  of  silver  wire,  which  is  drawn  through  holes  bored  in  the  end 
of  each  fragment.  In  oblique  fractures  wiring  is  indispensable. 
The  irritation  of  the  wire,  however,  is  a  disadvantage,  and  its  use 
should  be  avoided  whenever  possible.  If  a  wire  must  be  used 
it  should  not  be  buried,  the  ends  being  led  to  the  surface  and  envel- 
oped in  iodoform  gauze.  Screws,  clamps,  and  similar  appliances 
should  be  resorted  to  under  extraordinary  circumstances  only. 

Fig.  236  illustrates  the  case  of  a  man  of  thirty  years  who  sus- 
tained a  compound  fracture  of  the  leg.  Wiring  of  the  tibial  frag- 
ment was  undertaken,  as  is  evident  from  the  skiagraph.  Although 
the  same  process  was  repeated  three  times,  the  wire  sutures  always 
yielded,  so  that  the  fragments  separated  again.  This  was  caused 
by  the  fact  that  the  fibula  was  ignored  during  the  operative  steps.  If 
the  operation  had  not  been  undertaken  until  after  first  consulting 
the  Eontgen  rays,  it  would  have  been  found  that  the  fibula  was 


TREATMENT    OF    DEFORMED    FRACTURE        315 

fractured  twice  and  that  its  fragments  were  united  in  false  posi- 
tions. To  avoid  tension  in  the  suture  line  of  the  tibia,  the  fibula 
had  to  be  exposed  and  adapted.  If  the  surgeon  could  have  seen 
the  skiagraphic  result  of  his  case  he  would  surely  have  shortened 

the  fibula  in  proportion. 

As  the  skiagraph,  taken  six  months  after  the  injury  was  sus- 
tained, indicated,  the  two  wire  sutures  are  at  the  point  of  separa- 
tion again. 

This  case  is  reported  to  show  how  much  unnecessary  trouble 
and  disappointment  to  the  patient  as  well  as  to  the  surgeon  can 
be  avoided  by  a  simple  glance  with  the  rays. 

When  there  is  much  loss  of  bone  tis>ue.  implantation  of  a 
parallel  bone  may  be  recommended,  a  fibular  fragment,  for  in- 
stance, being  inserted  into  the  medullary  canal  of  the  tibia.  After 
successful  union,  the  formerly  thin  bone  sometimes  reaches  a  con- 


FlG. 


-Wire  Left  in  Situ  after  Suturing  the  Radius — Relations  Analo- 
gous to  Fig.  236. 


siderahle  size.  Thus  the  author  has  observed  development  of  the 
fibula  to  such  an  extent  that  the  circumference  of  its  middle  por- 
tion became  even  larger  than  that  of  the  tibia. 

Similar  conditions  are  illustrated  by  Fig.  237,  which  shows 


316 


THE    BOXTGEN    KAYS 


the  ulna  to  be  shorter  than  the  radius,  which  was  wired.  N"o 
union  took  place,  therefore.  The  silver  wire  was  buried  in  this 
case — a  procedure  not  to  be  advised. 

In  deformities  of  the  diaphyseal  ends  a  wedge  must  sometimes 
be  exsected,  in  order  to  secure  perfect  apposition.  Especially  in 
deformed  union  of  the  malleoli,  causing  abduction  of  the  foot,  this 

procedure  must  be  resort- 
ed to.  Prominent  bone 
portions  which  offer  an 
obstacle  to  perfect  reposi- 
tion must  be  removed  by 
the  chisel.  Such  frag- 
ments often  cause  pres- 
sure upon  an  adjacent 
nerve,  the  relief  from 
which  may  cure  neuritis 
or  paralysis.  The  pro- 
truding portion  is  chis- 
elled off  after  the  perios- 
teum is  carefully  lifted 
from  it.  Then  the  com- 
pressed nerve  must  be 
freety  exposed  and  prop- 
erly replaced.  The  peri- 
osteum is  united  with 
thin  catgut.  Conclusions 
upon  the  anatomical  con- 
dition of  the  compressed 
area  can  be  drawn  by  the  faradic  test,  which,  by  proving  the  in- 
tegrity of  the  nerve  below  the  injured  portion,  promises  restoration. 
In  the  course  of  time,  however,  degenerative  processes  may  be  ex- 
pected. Still,  even  under  such  circumstances,  restoration  is  ob- 
served after  the  relief  of  pressure. 

Pressure  may  also  be  caused  by  the  formation  of  callus  or 
fibrous  adhesions.  In  the  great  majority  of  cases  the  radial  nerve 
is  compressed.  Sometimes  the  nerve  is  found  embedded  in  a  regu- 
lar osseous  canal  or  tunnel,  in  which  case  Nature  had  admirably 
tried  to  create  a  special  protection  against  compression.  In  a  case 
of  this  kind  surgical  interference  appears  necessary  only  when 
the  nerve  is  kinked  at  its  entrance  or  exit. 


Fig.  238. — Diastasis  of  Fragments  Caus- 
ing Pressure  upon  the  Musculospiral 
Nerve. 


TREATMENT    OF    DEFORMED    FRACTURE        317 

Interposition  of  a  nerve  between  the  ends  of  the  bone  frag- 
ments is  another  cause  of  neuritis  or  paralysis.  Its  frequency 
seems  to  be  entirely  underestimated.  The  musculospiral  (radial) 
nerve,  especially,  shows  a  great  tendency  to  interposition,  which 
finds  its  explanation  in  the  spiral  track  in  which  it  winds  around 
the  bone  (compare  Figs.  1  t2,  14:5,  and  ^38).  Similar  dispositions 
are  shown  by  the  peroneal  nerve. 

If  the  contusion  of  the  nerve  is  not  severe,  and  the  incarcera- 
tion insignificant  at  the  time  the  fracture  is  sustained,  symptoms 
of  neuritis  or  paralysis  may  be  postponed  until  further  consolida- 
tion of  the  fragments  includes  the  nerve  in  callous  tissue. 

Nerve  interposition  may  be  suspected  whenever  there  is  intense 
pain  or  numbness  in  the  range  of  its  course.  By  pushing  the  lower 
fragments  towards  the  upper  in  a  vertical  direction  the  symptoms 
are  markedly  increased. 

In  fractures  of  the  lower  half  of  the  humerus  or  the  upper 
end  of  the  fibula  the  possibility  of  nerve  interposition  should  never 
be  lost  sight  of. 

The  Rontgen  rays  give  us  no  direct  information.  Still,  if  they 
show  diastasis  of  the  fragments  within  the  area  of  the  nerves  men- 
tioned, interposition  of  some  kind  must  be  assumed.  If,  in  longi- 
tudinal displacement,  the  diastasis  does  not  disappear,  no  matter 
how  the  position  of  the  fragments  be  changed,  and  if  crepitus  can- 
not be  perceived  during  these  manipulations,  the  assumption  of 
interposition  becomes  a  certainty.  This  interposition  may  be  sim- 
ply muscular  and  no  nerve  may  be  inclosed;  but  in  the  majority 
of  cases  nerves  are  drawn  in  with  the  muscular  tissue. 

The  skiagraph  Fig.  238  illustrates  a  condition  of  this  kind, 
which,  however,  was  not  recognised  in  its  initial  stage.  The  pa- 
tient, a  man  of  fifty  years,  sustained  a  subcutaneous  fracture  of 
the  humerus  and  a  multiple  compound  fracture  of  the  forearm  by 
extreme  violence.  Amputation  of  the  forearm  had  to  be  per- 
formed, while  the  fracture  of  the  humerus  was  treated  by  splints. 
A  few  days  after  the  accident  intense  pain  around  the  amputation 
wound  was  complained  of,  which  radiated  upward  alongside  the 
arm.  When  the  patient  was  seen  for  the  first  time  the  thin,  irregu- 
lar, and  fibrous  cicatrix  appeared  to  be  immovable.  Manipulations 
were  painful.  This  suggested  that  there  was  pressure  of  the  nerve 
ends  requiring  secondary  amputation.  The  bone  ends,  after  being 
trimmed,   were   covered   with   periosteum    and   a   thick   musculo- 


318  THE    RONTGEN    RAYS 

cutaneous  flap.  Four  weeks  thereafter  there  was  perfect  mobility, 
the  pain  around  the  stump  had  lessened,  but  still  persisted  along- 
side the  arm.  From  the  diastasis  between  the  fragments  of  the 
humerus,  as  it  is  shown  by  the  skiagraph,  it  was  concluded  that 
the  source  of  this  pain  was  at  the  fractured  area,  pressure  being 
exercised  upon  the  musculospiral  nerve  by  interposition.  This 
proved  to  be  true  when  the  author  made  an  incision  upon  the 
fractured  area,  in  which  he  found  a  small  bone  splinter  shifted 
between  the  two  diaphyseal  fragments  and  overbridged  by  en- 
sheathing  callus.  The  front  view  of  the  skiagraph  showed  this 
splinter  only  indistinctly,  but  a  side  view  proved  its  existence. 
Fibres  of  the  biceps  muscle  as  well  as  a  portion  of  the  musculo- 
spiral nerve  were  pulled  into  this  conglomerated  area  by  the  small 
splinter.  The  splinter,  as  well  as  the  ensheathing  callus,  which 
formed  a  superficial  bridge,  was  removed,  the  muscular  fibres 
pushed  backward,  and  the  nerve  dislodged  laterally.  The  frag- 
ments, after  being  trimmed,  were  united  with  silver  wire.  The 
pain  decreased  considerably,  but  continued  in  a  moderate  degree 
for  three  months  thereafter. 

Another  result  of  the  intervention  of  muscle,  as  well  as  of 
nerve  tissue,  is  the  development  of  pseudo-arthrosis. 

If  the  efforts  at  reposition  of  the  fragments  fail  to  free  the 
interposed  tissues,  the  injured  area  must  be  extensively  exposed. 
The  compressed  nerve  is  then  lifted  and  displaced  laterally  from 
the  fragments,  which  are  eventually  put  in  apposition  by  wiring. 
If  the  nerve  is  lacerated,  it  must  be  properly  trimmed.  If  it  is 
separated  in  its  continuity,  neurorrhaphy  must  be  undertaken.  In 
the  latter  event,  which  is  rare,  the  symptoms  are,  of  course,  well 
marked,  the  power  of  conduction  within  the  extent  of  the  nerve 
below  the  fractured  area  being  suspended. 

In  studying  the  aetiology  and  the  mechanism  of  deformed  frac- 
tures and  their  sequelae  the  question  is  obvious,  Why  not  prevent 
them  at  the  start?  Since  we  can,  with  more  or  less  accuracy,  esti- 
mate the  result,  why  wait  till  the  tissues  degenerate  and  the  de- 
formity becomes  established  ?  Before  the  advent  of  asepsis  the 
taissez  alter  policy  was  defended  through  the  fear  of  wound  com- 
plications, and  before  the  Rontgen  era  the  uncertainty  of  a  de- 
tailed diagnosis  offered  a  more  or  less  justifiable  excuse.  These 
times  had  passed  even  before  the  discovery  of  the  rays,  and  later 
the  genius  of  Kocher  emphasized  the  need  of  treating  irreducible 


TREATMENT    OF    DKKOUM  ED    FRACTURE 


319 


fractures  by  early  operation.  Eelferich,  McBurney,  Bull,  Berger, 
and  Ransohoff  followed  his  teachings.  But  they  did  it  spasmod- 
ically, without  following  a  logical  and  discriminate  manner,  while 
skiagraphy  shows  whether  a  displaced  bone  fragmenl  can  be  reduced 
or  not  on  the  day  it  is  fractured.  If  reduction  under  ansesthesia 
cannot  he  accomplished,  reposition  by  open  exposure  must  be 
attempted.  If  this  is  omitted,  the  fragments  may  present  an  ob- 
stacle to  important  functions.  In  deformities  caused  by  diaphy- 
seal fractures  much  interference  is  but  seldom  indicated.     But  in 


Fig.  239.— Fracture  of  Radial  Head,  showing  Considerable  Outward  Dis- 
placement.    (Compare  Figs.  240  and  24t.) 


spiral-shaped  and  multiple  fractures  situated  in  the  immediate 
vicinity  of  joints,  it  is  a  necessity,  if  the  function  of  the  joint  is 
to  be  preserved. 

The  question  whether  there  should  be  an  operation  or  not  is 
sometimes  settled  only  after  several  attempts  at  reposition,  con- 
trolled by  the  skiagraph,  have  been  made,  as  is  illustrated  by  the 
following  case : 

A  girl,  twenty-three  years  of  age,  fell  downstairs.  The  family 
physician,  who  was  called  immediately,  found  considerable  de- 
formity, which  he  corrected  to  a  great  extent.     There  was  an  im- 


320 


THE    KOXTGEtf    RAYS 


pression  at  first  that  backward  dislocation  had  taken  place,  but 
when,  after  a  week,  the  swelling  surrounding  the  whole  elbow  did 
not  subside,  the  patient  was  referred  to  the  author  for  examina- 


240. — Fractured  Radial  Head  Illustrated  by  Fig.  182  after  a  Futile 
Effort  at  Reduction.     (Compare  Figs.  239  and  241.) 


tion.  Before  resorting  to  skiagraphy  the  author  examined  the 
swollen  area  after  the  usual  methods  without  being  able  to  recog- 
nise any  marked  symptoms  of  fracture,  except  at  the  outer  aspect 
of  the  external  condyle.  But  the  skiagraph  revealed  the  presence 
of  the  fracture  of  the  head  of  the  radius  (Fig.  239),  associated 
with  considerable  displacement,  infraction  of  the  external,  and 
fracture  of  the  internal  epicondyle,  the  latter  injuries  without 
displacement.  Since  the  author  could  locate  the  displaced  radial 
fragment  so  well  by  the  rays,  he  assumed  that  he  could  now  also 
succeed  in  reducing  it.  But  he  was  not  able  to  palpate  it.  A 
fairly  large  number  of  physicians  tried  the  same,  but  none  could 
feel  it.  So  the  author  marked  the  position  of  the  fragment  as 
his  anatomical  knowledge  indicated  it,  and  pressed  inward.  Now 
he  applied  a  fenestrated  plaster-of-Paris  dressing,  through  which 
he  took  the  skiagraph.  This  showed  most  impolitely  that  he  had 
not  only  failed  in  his  efforts  at  reposition,  but  had  even  made  it 


TREATMENT    OF"DEFORMED    FRACTURE        321 

worse  (Fig.  340).  But  when  he  tried  to  reduce  it  in  the  extended 
position,  he  could  press  the  fragment  nearer  to  its  norma]  position. 
Then  it  was  that  he  was  encouraged  to  make  a  fourth  attempt  in 
the  same  position  of  the  arm,  and  this  time  he  succeeded  fully,  as 
skiagraph  Fig.  241  shows.  The  result  is  a  good  one.  Had*  the 
author  not  succeeded  in  reducing  the  fragment,  he  should  have 
exposed  it  freely  without  any  further  delay,  and  have  attempted 
to  reduce  it  unless  it  showed  so  little  cohesion  that  the  scant 
blood  supply  might  have  cut  off  nutrition,  in  which  case  he  would 
have  preferred  to  remove  it. 

Skiagraph  Fig.  241  was  taken  by  means  of  a  very  powerful 
hard  tube,  which  permitted  of  such  thorough  permeation  of  the 
plaster  of  Paris  that  wherever  the  layer  of  the  dressing  was  thin 
complete  translucency  was  obtained. 

Another  instance  of  conservative  advice  was  given  by  the  Ront- 
gen  rays  in  the  case  of  a  lady,  aged  thirty  years,  who  was  thrown 


Fig.  241.— Radial   Head   Reduced.     Taken    Through   the  Plaster-of-Paris 
Dressing.     (Compare  Figs.  239  and  240. ) 


against  a  stony  prominence  in  a  runaway  accident.  An  enormous 
hematoma  developed  in  the  region  of  the  elbow,  considerable 
oedema  at  the  same  time  extending  from  the  middle  of  the  humerus 
to  the  tips  of  the  fingers.    This,  of  course,  caused  marked  deform- 


322  THE    RONTGEN    RAYS 

ity.  There  were  crepitus  and  complete  loss  of  power  at  the  same 
time.  When  the  author  saw  the  patient  in  a  country  town,  far 
from  where  a  Rontgen  apparatus  could  be  secured,  he  succeeded 


Fig.  242.— Diastasis  of  Fragments  in  Fracture  at  the  Ulna. 
(Compare  Fig.  226.) 

in  making  the  diagnosis  of  the  presence  of  fracture  of  the  ole- 
cranon followed  by  considerable  forward  displacement  of  the  ulnar 
diaphysis.  The  decision  of  the  question  whether  there  were  any 
other  bone  injuries  was  left  to  subsequent  irradiation.  After  sev- 
eral unsuccessful  attempts  had  been  made  under  anaesthesia  to  dis- 
entangle the  diaphyseal  fragment,  which,  in  overlapping  the  radius, 
was  caught  in  the  muscular  tissue,  the  author  succeeded,  and  his 
impression  was,  that  perfect  approximation  between  the  diaphyseal 
fragments  and  the  olecranon  process  was  obtained.  The  arm  had 
been  kept  in  rectangular  position  for  nearly  three  days,  and  the 
immense  swelling  of  the  whole  limb  seemed  to  be  a  contra-indica- 
tion  for  an  effort  to  apply  an  extension  splint.  After  a  week, 
when  the  patient,  who  had  sustained  various  injuries  besides  that 
of  the  elbow,  was  able  to  travel,  a  skiagraph  was  taken  which  re- 
vealed the  normal  direction  of  the  diaphyseal  fragments,  but  a 
diastasis  between  it  and  the  olecranon  process  (Pig.  242).  An 
effort  was  made  to  shift  the  latter  towards  the  diaphysis,  which, 
after  a  palpatory  examination,  seemed  to  have  been  successful.  A 
plaster-of-Paris  dressing  was  applied,  therefore,  in  the  rectangular 
position.    Irradiation  through  the  dressing  showed  that  the  author 


TREATMENT    OF    DEFOEMED    FRACTURE        323 

had  error],  and  that  the  same  amount  of  diastasis  existed  as  before. 
It  seemed  to  him  that  the  gap  was  filled  with  muscular  tissue, 
therefore  he  was  unable  to  palpate  the  hiatus  between  the  bone 
fragments.  This  could  happen  so  much  more  easily  since  there  was 
still  considerable  swelling.  He  removed  the  dressing  again,  repeal- 
ing the  efforts  at  reposition  in  the  extended  position,  a  manoeuvre 
which  was  easier  than  a  week  before.  Through  the  new  plas- 
ter-of-Paris  dressing,  applied  in  the  extended  position,  the  irradia- 
tion was  again  tried,  which  proved  the  fragments  to  be  in  perfect 
apposition.  Another  skiagraph  (Fig.  243),  taken  after  the  re- 
moval of  the  plaster,  showed  ideal  union  four  weeks  after  the 
injury.  It  would  be  impossible,  in  fact,  to  infer  from  the  study 
of  this  skiagraph  that  there  ever  had  been  a  fracture,  a  point  not 
to  be  underestimated  from  a  medico-legal  point  of  view.  The 
inability  of  finding  any  evidence  by  palpation  and  the  perfect  func- 
tion of  the  arm  would  lead  to  doubt  as  to  the  serious  nature  of 


Fig.  243. —Ideal  Union  after  Fracture  of  the   Olecranon,  Three  Weeks 
after  the  Injury.     (Compare  Fig.  242. ) 

the  injury  had  not  a  skiagraph  been  taken  at  a  time  when  the 
diastasis  furnished  such  a  distinct  proof. 

There  are  more  instructive  points  in  this  case.     The  successful 
final  reposition  decided  whether  suturing  of  the  olecranon  should 


324  THE    RONTGEN    RAYS 

be  resorted  to  or  not.  We  have  learned,  furthermore,  that  the 
Rontgen  control  shows  distinctly  whether  the  dressing  is  better 
applied  in  the  extended  or  in  the  rectangular  position.  The  latter 
is  the  more  comfortable,  but  if  it  does  not  permit  reduction,  while 
the  less  comfortable  position  does  afford  it,  the  point  of  comfort 
should  not  receive  much  attention,  at  least  not  for  the  short  space 


Pig.  244— Oblique  Fracture  of  Olecranon  Wired. 

of  time  during  which  the  extended  position  would  be  indicated. 
If  coaptation  is  perfect,  the  position  can,  as  a  rule,  be  changed 
into  the  rectangular  after  two  or  three  weeks. 

Skiagraph  Fig.  244  may  serve  as  a  counterpart  of  this  case. 
It  represents  an  oblique  fracture  of  the  olecranon  by  a  fall  upon 
the  elbow. 

The  patient,  a  girl  of  twenty-three  years,  was  treated  in  the 


TEEATMENT    OF    DEFOKMED    FRACTURE        325 

extended  position  by  a  most  competent  physician.  Six  weeks  after 
the  injury  there  was  still  a  moderate  amount  of  -welling  in  the 
region  of  the  olecranon.  Palpation  revealed  the  presence  of  a 
gap  and  mobility  of  the  lower  triangular  fragment.  Any  effort 
at  motion  was  accompanied  with  intense  pain.  The  skiagraph 
showing  but  little  diastasis,  the  author  advised  immobilization  in 
the  overextended  position,  expecting  that  a  late  union  would  take 
place.  But,  when  ten  weeks  after  the  injury,  union  failed  to  occur, 
although  the  extreme  extension  seemed  to  have  held  the  fragments 
in  very  close  apposition,  the  author  exposed  the  fractured  area 
by  incision.  The  surfaces  of  both  fragments  were  covered  with 
fibrous  tissue  where  they  had  been  separated,  which  permitted  of 
free  motion.  By  excising  the  fibrous  layers  fresh  bony  surfaces 
were  obtained,  which  the  author  brought  into  close  approximation 
by  silver  wire.  No  reaction  followed,  and  the  result  was  perfect 
in  four  weeks.  The  method  by  which  the  holes  were  bored  and  the 
wire  passed  are  shown  by  the  skiagraph. 

In  a  man  of  twenty-two  years  an  enormous  degree  of  displace- 
ment in  osteo-epiphyseal  separation  of  the  head  of  the  humerus 
was  observed.  The  diaphyseal  end  was  shifted  alongside  and  in 
front  of  the  head  and  forced  between  it  and  the  skin.  The  pro- 
jecting fragment  lifted  the  skin  at  the  anterior  aspect  of  the 
shoulder.  The  accident  happened  during  wrestling  six  weeks  be- 
fore a  skiagraph  was  taken.  Subcoracoid  dislocation  had  been 
thought  of  first;  later  on,  symptoms  of  compression  of  the  bra- 
chial plexus  (paralysis)  had  developed.  Eefracturing  under  an- 
aesthesia being  impossible  after  so  long  a  time,  reposition  by  osteot- 
omy had  to  be  resorted  to.  A  longitudinal  incision,  beginning  at 
the  acromion,  was  made,  which  extended  straight  downward  to  the 
upper  third  of  the  arm.  To  this  a  transverse  incision  was  added 
at  the  upper  portion,  which  reached  the  inner  margin  of  the 
diaphyseal  fragment.  After  severing  the  periosteal  adhesions  with 
the  bone  knife,  and  the  fragments  which  had  united  in  juxtaposi- 
tion with  the  chisel,  it  was  tried  to  approximate  them.  This  was 
made  possible  only  after  the  diaphyseal  end  was  shortened.  The 
head  of  the  humerus  presented  a  thin  bone  shell,  which  could  not 
be  sewed  to  the  diaphysis  in  the  usual  manner.  The  author  there- 
fore excavated  the  head  with  the  bone  spoon  still  further,  trimming 
the  diaphyseal  end  at  the  same  time  in  such  a  manner  that  it  fitted 
into  the  excavation.    No  wiring  was  done.    The  fragment  could  be 


326 


THE    EOxYTGEN    RAYS 


kept  in  situ  by  immobilizing  the  arm  in  the  elevated  position  by- 
means  of  a  humerothoracic  plaster-of-Paris  dressing.  Although 
there  was  some  swelling,  combined  with  a  slight  elevation  of  tem- 
perature, for  the  first  few  days,  the  wound  healed  by  first  inten- 
tion. The  paralytic  symptoms  have  greatly  improved,  still  there 
is  some  loss  of  power. 

While,  as  referred  to  before,  articular  fractures  often  demand 
early  operative  interference,  for  the  purpose  of  proper  reposition, 
fractures  of  the  diaphyses  very  seldom  require  such  procedures. 


Fig.  245. — Fracture  of  Diaphysis  of  Humerus  Associated  with  Separation 

of  Fragment. 


It  may  happen  in  the  multiple  type  that  bone  splinters  are  so  far 
separated  from  the  fractured  area  that  their  reposition  is  impos- 
sible. If  they,  as  the  Rontgen  examination  will  determine,  are 
liable  to  offer  an  obstacle  to  the  functional  ability  of  the  limb,  they 
must  be  exposed.  If  there  is  sufficient  periosteal  coherence  war- 
ranting proper  nutrition  of  the  fragment,  it  may  be  replaced  and 
fixed  by  wiring.     If  not,  it  had  better  be  removed. 

Fig.  245  illustrates  the  spiral-shaped  fracture  of  the  humerus 
in  a  stout  man,  aged  forty-six  years,  sustained  by  severe  violence 
four  days  before  the  skiagraph  was  taken  (patient  presented  to 
the  New  York  State  Medical  Association,  October,  1902).  The 
slight  shortening  of  the  arm  was  explained  by  the  juxtaposition  of 


TREATMENT  OF  DEFORMED  FRACTURE   .'527 

the  fragments,  as  is  evident  from  the  skiagraph.  There  was  an 
enormous  swelling,  which,  in  connection  with  the  panniculus  adi- 
posus  of  the  patient,  rendered  palpation  so  much  more  difficult. 
False  motion,  of  course,  crepitus  also,  being  well  marked,  the 
diagnosis  of  the  presence  of  a  fracture  of  the  upper  third  of  the 
humerus  could  easily  he  made  without  the  rays.  But  the  presence 
of  a  large  isolated  bone  splinter  was  not  disclosed  before  skiagraphy 
was  resorted  to.  From  the  study  of  the  skiagraph  it  could  be 
presumed  that  reposition  of  the  fragment,  embedded  in  an  area 
of  bloody  effusion  and  lacerated  and  inflamed  tissues,  could  not 
be  attained  by  simple  manual  apposition.  It  was  easy  to  persuade 
the  patient  that  the  operation  was  a  necessity  by  simply  showing 
him  the  loose  splinter  on  the  skiagraph.  On  the  sixth  day  after 
the  injury  the  author  exposed  the  fractured  area  by  an  incision 
alongside  the  outer  margin  of  the  biceps  muscle.  The  site,  as  well 
as  the  length,  of  the  incision  was  determined  by  measuring  the  dis- 
tances in  the  skiagraph  and  transferring  their  relations  to  the 
patient's  arm.  The  large  splinter  proved  to  be  entirely  detached 
from  the  diaphyseal  fragments,  and  as  there  was  no  periosteal 
cohesion,  it  seemed  to  the  author  risky  to  leave  it,  although  there 
was  no  obstacle  to  reducing  and  fixing  it  by  wiring.  The  removal 
was  certainly  safer  and  would  not  interfere  with  the  apposition  of 
the  fragments.  After  the  portions  of  the  biceps  and  triceps  mus- 
cles, which  had  intervened,  were  disengaged  from  the  diaphyseal 
fragments,  they  were  brought  in  apposition.  Xo  wiring  was  done. 
A  humerothoracic  dressing  of  plaster-of-Paris,  applied  immediately 
after  the  operation,  was  left  in  situ  for  three  weeks.  Recovery  was 
uninterrupted. 

As  another  skiagraph,  taken  four  months  after  the  opera- 
tion, showed,  union  was  faultless,  and  the  deficiency  caused  by  the 
removal  of  the  isolated  fragment  was  filled  up  by  callus.  Functional 
ability  was  perfect.  If  the  bone  splinter  had  not  been  recognised 
at  an  early  stage,  and  had  consequently  been  left,  it  would  have 
served  as  an  impediment  between  the  biceps  and  triceps  muscles, 
thereby  arresting  their  contractibility.  Thus  we  see  that  the  ques- 
tion of  shortening  in  fracture  of  the  diaphysis  of  the  humerus  is  of 
less  importance  than  that  of  the  special  deformities  which  may 
disturb  the  functional  ability  of  the  extremity. 

On  the  contrary,  in  fractures  of  the  femoral  diaphysis,  the  ques- 
tion of  the  shortening  is  more  important  than  that  of  the  deform- 


328 


THE    RONTGEN    RAYS 


ity  itself.  Of  course,  if  there  is  considerable  projection  of  the 
overlapping  fragment,  undue  pressure  upon  the  soft  tissues  may 
produce  symptoms  at  the  point  of  fracture  which  demand  interfer- 
ence. But,  as  a  rule,  it  is  the  shortening  which  suggests  opera- 
tive interference,  when 
the  fragments,  after  be- 
ing slipped  by  each  other, 
become  united  in  juxta- 
position. If,  in  fracture 
of  the  femoral  diaphysis, 
therefore,  the  fragments 
have  only  been  put  in  the 
proper  direction,  without 
regard  to  whether  there  is 
also  a  lateral  deviation  or 
undue  prominence  of  one 
of  the  fragments,  the 
function  of  the  leg  is,  as 
a  rule,  but  little  dis- 
turbed. This,  in  fact,  is 
the  least  which  can  be 
expected  of  a  physician 
who  attempts  the  treat- 
ment of  fractures.  Juxtaposition  can,  therefore,  never  be  par- 
doned. And  this  is  nearly  the  only  condition  which  demands 
osteotomy,  and  which  cannot  be  remedied  by  any  other  procedure. 
In  juxtaposition  the  attempt  at  bloodless  refracture  appears  to 
be  a  most  adventurous  undertaking,  if  one  simply  looks  at  the 
skiagraph  of  a  condition  of  this  kind.  It  is  unwise  to  attempt 
it,  because  the  artificial  fracture-line  would  not  separate  the  frag- 
ments where  they  are  attached  to  each  other  by  sideward  union, 
but  would  run  through  the  fragments  in  a  transverse  direction 
(compare  Fig.  246).  And  then  extension  would  not  elongate  the 
shortened  thigh.  But  osteotomy  permits  of  separation  alongside 
the  line  of  false  union,  and  extension  will  bring  the  lower  frag- 
ment down,  provided  too  much  time  has  not  elapsed  since  the 
fracture  was  sustained. 

As  to  old  dislocations,  the  respective  chapters  are  referred  to. 
After  a  few  weeks  have  elapsed  bloodless  reduction  is  rarely  pos- 
sible.    In  a  case  of  backward  dislocation  of  the  forearm,  which 


Fig.    246.— Juxtaposition    in   Fractcre   of 
Femur. 


TREATMENT    OF    DEFORMED    FRACTURE        329 

on  account  of  the  enormous  swelling  around  the  elbow  was  taken 
for  a  fracture,  four  months  had  elapsed  after  the  injury.  Reposi- 
tion after  so  long  a  period  could  not  be  expected,  but  a  semilunar 
incision  should  he  made,  the  convexity  of  which  would  be  directed 
upward  around  the  olecranon,  exposing  it  as  well  as  the  radius 
and  liberating  them  by  excising  the  capsular  fragments  and  the 
cicatricial  tissue.  Whatever  tissue  present  an  obstacle  must  either 
be  divided  or  removed.  There  is  no  need  for  resecting  any  bone 
portions. 

Fig.  246  illustrates  the  femur  of  a  boy  of  nine  years,  taken 
three  months  after  it  was  fractured.  The  union  in  juxtaposition 
explains  why  there  was  shortening  to  the  extent  of  nearly  three 
inches.  After  the  fragments  had  been  separated  by  the  chisel, 
forcible  extension  succeeded  in  restoring  the  limb  to  its  full  length. 


Fig.  247.— Transverse  Fracture  of  Femur  Non-united.     Angular  Deformity- 
Corrected  Eleven  Weeks  after  the  Injury. 


The  ends  were  trimmed  and  adjusted  by  a  thick  piece  of  silver  wire. 
Recovery  was  uneventful,  and  the  result  perfect. 

It  is  needless  to  say  that  such  operations  are  an  absolute 
necessity,  not  so  much  because  of  the  undue  pressure  at  the  area  of 
faulty  union,  as  on  account  of  the  shortening,  because  such  may 


330  THE    KONTGEN    KAYS 

destroy  the   chances   of   a  successful   career   for   the   unfortunate 
patient. 

Of  course,  such  deformities  should  not  occur  at  all.     It  is  the 
duty  of  the  surgeon  who  is  called  to  correct  them  to  answer  the 


Fig.  24S. — Fracture   of   Lower  End  of   Radius    followed   by  Upward   and 
Sideward  Displacement. 

question  of  the  crippled  patient  why  his  limb  was  not  put  into 
the  proper  position  at  once,  by  defending  his  brother,  because  we 
all  are  liable  to  err.  Still  it  would  be  "  a  consummation  devoutly 
to  be  wished  "  that  crippled  conditions  of  this  kind  should  be  due 
exclusively  to  the  disobedience  of  the  patients  to  the  surgeon's 
directions. 

Figs.  33  and  35  illustrate  similar  cases,  the  correction  of 
which  fortunately  could  be  done  by  simple  osteoklasis.  Fig. 
247  illustrates  the  case  of  a  boy  of  sixteen  years  who  sus- 
tained an  infratrochanteric  fracture.  The  extensive  angulai  de- 
formity was  not  reduced.  Union  did  not  take  place  because  the 
outer  margins  of  the  fragments  did  not  touch  each  other,  so  that 
a  gap  was  the  consequence.  Nature  tried  to  correct  this  condition 
by  throwing  out  a  large  amount  of  callus  at  the  adjoining  margins 


TREATMENT    OF    DEFORMED    FRACTURE        331 

of  the  inner  aspect,  but  this  did  nut  suffice.  Osteoklasis  resulted 
in  perfect  recovery. 

While  in  articular  fractures  reposition  is  often  a  very  difficult 
procedure  and  failure  a  most  excusable  occurrence  in  non-compli- 
cated fractures  of  the  diaphyses,  reduction,  if  attempted  with  a 
minimum  dose  of  common  sense,  must  always  be  succeessful. 

Figs.  248,  249,  250,  and  251,  for  instance,  represent  very  severe 
fracture-types  in  a  man  of  thirty  years  who  had  fallen  from  a  con- 
siderable height.  Fracture  of  the  upper  end  of  the  ulna  associated 
with  sideward  dislocation  of  the  radius  of  the  right  arm.  and  frac- 
ture of  the  lower  end  of  the  radius  associated  with  upward  dislo- 
cation of  the  lower  fragment,  were  sustained  (  fig.  248).  Xo  effort 
at  reduction  was  made  for  four  weeks.     The  author  tried  to  reduce 


Fig.  249. — Whist  aftek  Removal  of  Displaced  Fragment. 
(Compare  Fig.  248.) 

the  displaced   fragment  after  having  it   exposed,   but  this   being 
impossible  it  was  exseetecl  (Fig.  249).    The  result  was  good. 

Reposition  of  the  displacement  of  the  elbow  (Fig.  250)  would 
certainly  have  been  successful  if  attempted  shortly  after  the  in- 
jury,  while   that   of  the   radial   end   would   probably   have    been 


Pig.   250.— Fracture   of   Upper   End   of   Ulna    Associated  with   Sideward 
Dislocation  of  Radius.     (Compare  Figs.  251  and  252.) 


333 


TREATMENT    OF    DEFORMED    FRACTURE        333 

impossible.      Bui   an  efforl   should  al    leasl    have  been   made.     If 
unsuccessful,    ii    should    have   been    reduced    by  open    incision   or 

removed. 

When  it  was  done  five  week.-  after  the  injury  Ligamentous  rem- 
nants had  to  be  exsected  in  order  to  permil  of  downward  pressure 
of  the  prominent  diaphysis.  At  first  it  was  tried  to  reduce  the  dis- 
placement in  a  bloodless  manner.  But  while  it  was  possible  to  lacer- 
ate the  adhesions,  so  that  the  arm  could  be  broughi  into  the  rec- 
tangular position  (Fig.  251),  the  fragments  could  not  be  approx- 
imated.    The  elbow  was  exposed  then  five  days  after  the  osteotomy 


Pig.  251.— Elbow  After  an  Effort  to  Reduce  the  Fragments. 
(Compare  Figs.  250  and  252.) 

of  the  wrist.  After  the  fibrous  adhesions  were  dissected  the  dis- 
placed ulnar  diaphysis  could  be  approximated  to  the  fragment, 
which  consisted  mainly  of  the  olecranon.  The  radius  followed  its 
fellow  then  without  much  difficulty.  The  ulnar  fragments  were 
kept  together  by  a  silver-wire  suture  (Fig.  252).  The  result  was 
nearly  perfect.  The  author  is  convinced  that  if  the  Rontgen 
method  had  been  used  early  in  this  case  the  skiagraph  would 
have  appealed  strongly  to  the  medical  conscience. 

Fig.   253    illustrates   the   modus  operandi  in  the   osteoplastic 
operation  of  Pirogoff.     The  patient,  a  girl  of  six  years,  whose 


334  THE    RONTGEN    RAYS 

skiagraph  was  taken  three  weeks  after  the  operation,  sustained  a 
compound  fracture  of  the  foot,  a  heavy  iron  bar  having  fallen  on 
it.  Expectant  treatment  was  resorted  to  for  two  weeks  until  the 
foot  became  black.  There  was  a  small  area  of  vital  tissue  at  the 
heel  which  in  connection  with  a  fragment  of  the  calcaneum  could 
be  utilized  for  the  Pirogoff  method.  Thus  the  shortening  of  the 
foot  was  practically  overcome.  The  author  favours  inserting  a 
screw  in  order  to  secure  approximation,  especially  under  such  cir- 
cumstances. 

In  a  severe  injury  of  this  kind  a  skiagraph  should  be  taken  at 
once  in  order  to  ascertain  the  extent  of  the  injury,     Bone-splin- 


Fig.  252. — Case  Illustuated  by  Pig.  250,  after  Bloody  Reposition. 
(Compare  Fig.  251.) 

ters  may  be  reduced  if  in  connection  with  the  periosteum,  or 
removed  if  there  is  no  more  hope  for  agglutination.  In  the  case 
described  a  partial  resection,  performed  in  time,  and  under  the 
guidance  of  the  Rontgen  rays,  might  have  saved  the  foot. 

Fig.  254  shows  the  effect  of  a  compound  fracture  of  the  lower 
end  of  the  ulna,  which  was  produced  by  machine  force  in  an 
engineer  of  thirty-three  years.  Two  ulnar  splinters  were  shifted 
over  the  anterior  surface  of  the  radius,  which  caused  a  promi- 
nence there.  On  palpation  this  prominence  left  the  impression 
of  the  presence  of  callus-formation  as  it  is  observed  after  badly 
united  fractures  of  the  lower  end  of  the  radius,  this  fact  beinsr 


TREATMENT    OF    DEFORMED    FRACTURE        335 


responsible   for  the  pessimistic  advice  given   by  the  various  sur- 
geons  who   though!    the  "callus"    to   be  ample   proof   for   their 
diagnosis:   fracture   of  the   lower   cud    of    radius    associated    with 
compound    fracture    of    the    ulna — no    skiagraphic    corroboration 
being  sought.    The  function  of  the  hand  was  totally  destroyed  by 
the  defect  iu  the  ulna,  and  furthermore  by  the  intervention  of  the 
two    splinters    w  h  i  c  h 
served   as   foreign    bod- 
ies  between   the   radius 
and  the  extensors.     The 
skiagraph   suggested   to 
the     author     that     lie 
should   utilize   one   evil 
for     the     compensation 
of  the  other,   viz.,   dis- 
placing    the     splinters 
and     implanting    them 
into  the  defect. 

This  was  done  by 
first  chiselling  off  the 
smaller  of  the  two  frag- 
ments. When  an  at- 
tempt was  made  to  dis- 
place it  toward  the  ul- 
nar defect,  the  small 
periosteal  bridge  yield- 
ed so  that  nutrition 
seemed  to  be  too  much 
impaired  to  warrant 
successful  agglutina- 
tion. It  was  removed 
therefore.  The  larger 
bone-fragment  could  be 
displaced  in  such  a 
manner    that    a    large 

periosteal  flap  remained  in  cohesion  with  the  radius.  At  the  same 
time  the  remnant  of  the  ulnar  end,  mainly  consisting  of  its  head, 
was  mobilized  from  its  synostosis  with  the  inner  surface  of  the 
radial  end  and  turned  in  the  longitudinal  direction:  There  was  no 
reaction,  and  eight  weeks  after  the  operation  skiagraphic  evidence 


Fig.  253. —Fragment  of  Caucaneum  Adjusted 
to  the  Tibia  by  a  Screw  after  Pirogoff's 
Amputation. 


336  THE    RONTGEN    RAYS 

showed  that  the  splinter  had  established  itself  fully  in  the  defect, 
It  had  been  fastened  there  by  a  few  periosteal  sutures  consisting  of 


Fig.  254. — Compound  Fracture  of  Ulna. 

thinnest  catgut,  but  at  the  same  time  it  was  held  in  situ  by  a  rubber 
drainage-tube,  pressed  into  the  interosseous  space  and  held  by  two 
narrow  strips  of  adhesive  plaster,  after  the  principle  of  the  au- 


Fig.  255. — Multiple  Fracture  of  the  Lower  End  of  the  Radius. 


TREATMENT    OF    DEFORMED    FRACTURE 


337 


thor's  metacarpal  dressing,  illustrated  by  Fig.  167.  In  harmony 
with  the  perfect  restoration  of  the  anatomical  condition,  the  func- 
tional result  was  perfect. 

The  detailed  description  of  this  case,  which  nui-i   be  regarded 


Fig.  256. — Tibia  Fractured  bt  Gun-shot. 


a  surgical  triumph  of  skiagraphy,  and  the  illustrations,  will  be 
found  in  the  Fortschritte  der  Rontgenstrahlen — Hamburg. 

Fig.  255  illustrates  a  multiple  intra-articular  fracture  of  the 


338  THE    RONTGEN    EAYS 

lower  radial  end  in  a  man  of  fifty  years.  Under  the  guidance  of 
the  rays  the  author  succeeded  in  reducing  the  fragments,  which 
were  upwardly  and  side  war  dly  displaced,  so  that  the  normal  wrist 
action  was  nearly  restored. 

As  to  the  principles  of  correcting  deformities  at  the  lower  end 
of  the  radius,  see  page  231. 

The  fallacy  of  the  theory  that  the  thinness  and  the  great  force 
of  the  modern  bullet  would  cause  a  clean  canal-like  foramen  was 
proved  by  the  author  in  March,  1896,  when  the  commander  at 
Governor's  Island  was  courteous  enough  to  permit  the  following 
experiment :  A  freshly  amputated  leg  was  fired  at  from  a  distance 
of  50  yards  with  the  Krag-Jorgensen  rifle.  This  showed  the  most 
destructive  effect  upon  the  tibia,  as  is  evident  from  the  skiagraph 
No.  256,  taken  immediately  afterward.  It  is  the  lateral  trans- 
mission of  the  energy  of  the  new  projectile  which  is  so  destructive, 
at  a  distance  up  to  350  metres,  at  least,  As  is  generally  known, 
the  size  of  the  army  bullet  was  reduced  from  0.7  to  0.3  inch,  and  its 
rapidity  increased  from  400  to  600  inches  per  second,  its  pene- 
trating force  being  about  six  times  more.  (See  the  Rontgen  Rays 
in  Surgery,  International  Medical  Magazine,  June,  1897.) 


CHAPTER    XVII 
THE  MEDICO-LEGAL  ASPECTS  OF  THE  RONTGEN  RAYS 

Even  the  most  skilful  experts  in  fractures  have  ceased  to  deny 
that  there  is  an  enormous  number  of  bone  injuries,  which,  in  for- 
mer years,  could  not  be  properly  recognised,  the  general  symptoms 
being  either  obscure  or  veiled  by  the  swelling  of  the  surrounding 
tissues.  The  mistakes  made  in  differentiating  fractures  from  dis- 
locations, contusions,  distortions,  or  tumefactions  were  innumer- 
able; but  they  could  be  proved  as  such  only  under  extraordinary 
circumstances.  The  Eontgen  rays  have  brought  about  a  revolu- 
tion. They  show  the  conditions  as  they  are,  and  are  impolite 
enough  to  do  this  without  the  slightest  regard  for  great  authori- 
ties. No  wonder  that  such  brusque  information  was  received  with 
a  feeling  of  uneasiness,  often  by  the  very  men  who  should  have 
been  but  too  glad  to  learn  of  their  diagnostic  errors  in  order  to 
correct  them.  As  is  known,  the  errors  made  in  the  interpretation 
of  skiagraphs,  of  which  so  much  was  then  heard,  supplied  a  favour- 
ite argument  in  defence  of  their  procrastination. 

We  have  learned  now  that  our  misinterpretations  were  caused 
by  insufficient  anatomical  knowledge,  as  well  as  by  technical  short- 
comings with  which  the  rays  had  nothing  to  do.  Officious  friends, 
inconsiderate  and  malicious  confreres,  and  shyster  lawyers  heralded 
and  misapplied  the  great  discovery  and  succeeded  for  a  while  in 
discrediting  it  even  among  those  members  of  the  medical  profes- 
sion who  had  begun  to  appreciate  its  great  value.  But  these  times 
have  passed.  The  Kontgen  rays  no  longer  need  a  gladiator  in  the 
medical  arena,  but  their  recognition  in  the  courts  leaves  much  to 
be  desired. 

Since  it  is  accepted  by  the  medical  profession  that  a  plate, 
which  is  accurately  made  by  a  physician  specially  trained  in  skiag- 
raphy, and  interpreted  by  an  expert,  gives  most  valuable  informa- 
tion which  cannot  be  obtained  otherwise,  the  court  should  regard 
it  its  duty  to  acknowledge  this  fact,  and  avail  itself  of  it  in  the 

339 


340  THE    RONTGEN    RAYS 

interest  of  justice.  Especially  the  judge  of  the  modern  era  of 
humanity  in  contrast  to  the  obsolete  representative  of  the  old 
dogma  "Fiat  justitia,  pereat  mundus!"  must  see  a  valuable  ally 
in  this  most  wonderful  discovery  of  the  last  century. 

What  a  triumph  for  suffering  mankind  are  the  numerous  cases 
in  which  veteran  soldiers,  contemptuously  treated  as  malingerers 
before  the  courts,  can  now  show  their  skiagraphic  proof  of  the 
presence  of  foreign  bodies.  A  patient  whose  body  harbours  a  bul- 
let, has,  indeed,  a  very  good  reason  to  complain.  The  number  of 
patients  who  submitted  to  unnecessary  surgical  operations  because 
foreign  bodies  were  suspected,  but  not  found,  and  the  still  larger 
number  of  those  who  were  not  advised  to  submit  to  operations, 
although  they  were  needed  on  account  of  the  non-suspected  pres- 
ence of  foreign  bodies,  is  legion. 

Long  before  the  Rontgen-ray  era,  when  the  author  was  a  young 
assistant,  a  woman  was  referred  to  him  for  an  obscure  swelling  along 
the  first  phalanx  of  the  left  index-finger.  The  anamnesis  revealed 
that  the  swelling  had  come  on  slowly  after  she  had  wounded  herself 
with  a  needle.  She  reported  that  the  needle  had  broken,  but  that 
the  fragment  was  pulled  out  by  herself.  There  was  but  little  pain, 
but  much  functional  disturbance.  The  impression  prevailed  that 
there  was  an  inflammatory  process  caused  by  an  infected  needle. 
Later,  when  fomentations  and  immobilization  were  of  no  avail, 
rheumatism,  osteitis,  and  then  tuberculosis  was  suspected,  and, 
besides  the  application  of  tincture  of  iodine,  internal  medicines 
were  administered.  Xo  improvements  being  obtained,  all  the  text- 
books available  for  information  were  studied,  but  scientific  thirst 
was  not  quenched.  The  old  routined  chief  whose  advice  was  then 
sought  suggested  that  an  exploratory  incision  should  be  made. 
How  great  was  the  surprise  when  a  small  needle-fragment  buried 
alongside  the  phalanx  was  found  !  The  author  has  never  forgotten 
the  feeling  of  humiliation  which  overcame  him  then  in  the  pres- 
ence of  the  patient.  But  he  believes  lie  did  not  stand  alone  in  this 
experience.  Solamcn  miseris,  socios  habuisse  malorum!  To-day  a 
simple  glance  with  the  fluoroscope  would  press  the  extraction  for- 
ceps into  the  hands  of  the  surgeon. 

Years  ago  the  author  demonstrated  a  man  before  the  Surgical 
Section  of  the  New  York  Academy  of  Medicine  who  carried  a  thick 
glass  splinter  underneath  his  zygoma  for  thirty-eight  years,  expe- 
riencing but  little  pain,  until,  shortly  before  Rontgen's  discovery,  a 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  341 

swelling  below  his  eye  led  him  to  seek  medical  care.  The  swelling 
was  regarded  as  a  malignant  growth.  He  lived  in  a  country  town, 
and  was  advised  to  go  to  New  York  and  have  his  superior  maxilla 
resected.  On  making  an  incision  the  author  found  the  glass  splin- 
ter, and  when  the  patient  saw  it,  he  remembered  that  when  a  boy 
he  was  wounded  in  his  lace  by  the  explosion  of  a  glass  bottle  con- 
taining gunpowder.  The  facial  wound  bad  healed  without  reac- 
tion. In  this  case  also  the  Rontgen  rays  would  have  made  the 
nature  of  the  growth  clear  at  once. 

An  odd  pendant  to  the  needle  case  is  illustrated  by  the  skia- 
graph of  the  foot  of  a  dwarf  (Fig.  25?)  made  two  years  ago. 
For  about  two  years  the  hero  of  the  tragic  comedy  had  been  a 
round-trip  patient  in  most  of  the  reputed  clinics  of  Xew  York 
city.  He  showed  a  slight  swelling  at  the  outer  aspect  of  his  foot, 
which  was  diagnosticated  as  periostitis,  osteitis,  osteoma,  osteo- 
sarcoma, beginning  tuberculosis,  rheumatism,  arthritis,  syphilitic 
proliferation  or  exostosis,  badly  united  fracture,  etc.  Later  on 
amputation,  as  well  as  exploratory  incision,  was  advised.  After 
having  suffered  for  more  than  two  years,  he  was  ready  now  to 
submit  to  anything  which  would  relieve  him  from  the  pain  he  suf- 
fered while  walking.  The  author  was  unable  to  make  a  diagnosis 
with  the  usual  methods,  but  the  Rontgen  rays  cleared  up  the  situ- 
ation at  once,  showing  a  needle  in  the  sole  of  his  foot.  When  the 
patient  was  informed  of  this  fact,  he  remembered  that  about  two 
years  ago,  while  sleeping  on  a  lounge,  he  fell  on  the  carpeted  floor 
and  noticed  a  sharp  pain  in  his  foot,  which  he  explained  by  the 
fall  itself.  He  had  undoubtedly  fallen  on  a  needle  sticking  out  of 
the  floor,  and  by  walking  he  had  shifted  it  up  into  the  joint,  from 
which  it  was  removed  under  considerable  technical  difficulties.  It 
is  needless  to  say  that  his  "  rheumatism  "  disappeared  at  once. 

Much  more  serious,  from  the  standpoint  of  humanity,  is  the 
following  case,  reported  by  Dr.  L.  Passower,  Riga  (Aerztliche 
Sachverstaendigen  Zeitung,  iSTo.  15.  1901).  In  November,  1897, 
a  young  farmer,  suffering  from  a  swelling  of  his  foot,  was  ad- 
mitted to  the  surgical  division  of  the  army  hospital  of  Riga  (Rus- 
sia) for  observation.  Being  a  recruit  he  was  expected  to  serve 
his  military  term.  But  a  year  before  a  mass  weighing  35  pounds 
had  fallen  on  his  leg,  causing  an  injury  which  compelled  him  to 
stay  in  bed  for  three  months.  It  was  reported  that  during  that 
time  the  foot  had  appeared  much  swollen  and  ecchymotic.     When 


342  THE    RONTGEN    EAYS 

admitted  to  the  service  of  Dr.  Passower  at  the  military  hospital  he 
was  limping  and  complained  of  a  continuous  pain  in  his  foot. 

He  was  assigned  a  bed  among  old  soldiers,  who  were  requested 
to  watch  him  closely,  as  he  was  suspected  to  be  a  malingerer. 
Three  days  after  admission  Dr.  Passower  received  an  anonymous 


Fig.  257. — Needle  in  the  Foot  or  a  Dwarf. 

letter,  signed  by  "  a  friend  of  the  recruit,"  which  contained  the 
information  that  the  patient  had  produced  the  swelling  himself, 
constricting  his  thigh  and  injecting  medicamentous  substances 
underneath  his  skin.  Dr.  Passower  stated  that  he  did  not  pay 
much  attention  to  this  communication,  but  deemed  it  his  duty  to 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  343 

order  a  still  closer  watch  by  adding  a  subaltern  medical  officer 
(Feldseheer)  and  a  professional  nurse  to  his  outpost.  Besides 
this,  he  as  well  as  his  assistants,  visited  the  poor  victim  repeatedly 
and  unexpectedly  during  night  time,  but  were  never  able  to  dis- 
cover anything  wrong.  After  two  weeks  the  oedema  had  subsided, 
but  the  tarsus  still  remained  thickened,  motion  of  the  ankle-joint 
also  remaining  painful.  Especially  pressure  on  the  scaphoid  bone 
produced  intense  pain.  As  soon  as  the  bandages  were  removed 
the  oedema  returned.  So  Dr.  Passower  came  to  the  conclusion 
that  the  patient  suffered  from  a  chronic  inflammatory  process  of 
his  tarsal  bones,  produced  by  an  injury.  The  possibility  of  a  frac- 
ture of  one  of  the  bones  was  also  duly  considered. 

After  four  weeks'  observation  he  was  presented  to  the  medical 
board  of  the  hospital,  which  suggested  that  he  should  be  exempt 
from  military  service  for  a  year.  It  was  expected  that  the  swelling 
would  gradually  disappear  if  the  patient  could  enjoy  rest  at  home 
and  regiilar  treatment.  But  the  military  commission  at  Riga  did 
not  accept  this  suggestion,  because  one  of  its  physicians  insisted 
upon  the  theory  of  the  artificial  origin  of  the  swelling.  So  the 
unfortunate  candidate  was  sent  to  the  city  hospital  of  Riga,  where, 
after  a  second  examination,  he  was  accused  of  having  injured 
himself  by  constriction  and  puncture  in  order  to  get  rid  of  his  mili- 
tary obligations.  So  he  was  delivered  to  the  public  prosecutor, 
but  set  free  after  a  long  trial,  and  especially  through  the  efforts 
of  Dr.  Passower. 

A  few  weeks  later  he  was  again  arrested  and  sentenced  to  three 
months'  solitary  imprisonment  for  self-mutilation.  Now  Dr. 
Passower  recommended  transferring  the  criminal  to  the  clinic  of 
Prof.  W.  W.  Koch  in  Dorpat,  in  order  to  obtain  a  skiagraph.  This 
was  at  last  permitted,  and  so  Professor  Koch  had  a  chance  to 
ascertain  that  there  was  a  fracture  of  the  astragalus,  which  had 
caused  sinking  of  the  sustentaculum  of  the  astragalus.  The  pa- 
tient appealed  to  a  higher  court,  which  dismissed  the  previous  sen- 
tence. At  the  end  of  February,  1900,  the  Government  referred 
him  back  to  the  military  hospital  in  Eiga,  where  he  was  skia- 
graphecl.  (It  seems  that  a  Eontgen  apparatus  was  not  obtained 
in  this  university  town  until  then.)  The  evidence  in  favour  of  the 
"  criminal "  was  too  overwhelming,  and  so  he  was  declared  unfit 
for  military  service. 

Thus  an  honourable  man  was  virtually  imprisoned  during  a 


344  THE    BONTGEN    KAYS 

period  of  three  years.  If  a  skiagraph  had  been  taken  at  the  time 
of  his  admission  to  the  military  hospital  (fully  two  years  after 
the  publication  of  Bontgen's  discovery),  the  whole  procedure  of 
ignorance  and  malicious  arrogance  would  not  have  been  set  in 
motion,  and  the  psychical  torture  of  another  poor  individual  would 
have  been  rendered  impossible.  In  the  face  of  the  skiagraphic 
illustration  of  the  fracture  of  the  most  important  bone  of  the  foot- 
skeleton,  no  judge  and  no  jury  would  have  dared  to  dispute  the 
claims  of  the  patient. 

The  counterpart  is  represented  by  a  case  reported  several  years 
ago  (Medical  Becord,  August  17,  1901)  which  showed  how  impor- 
tant for  proper  interpretation  the  knowledge  of  anatomical  details 
is.  It  has  occurred  to  the  author  as  well  as  to  others  that  the  nor- 
mal os  intermedium  cruris  (os  trigonum  tarsi)  was,  after  a  single 
exposure,  taken  for  a  fragment  severed  from  the  astragalus.  In 
the  author's  case  a  fracture  of  the  fibula  was  present,  but  the  first 
skiagraph  suggested  the  presence  of  a  tibial  fragment  also.  But 
this  was  cleared  up  by  a  subsequent  exposure  in  a  different  projec- 
tion-plane, as  mentioned  previously.  As  mentioned  in  the  section 
on  the  foot  (page  170),  the  os  intermedium  cruris  is  a  typical 
part  of  the  tarsus  of  all  mammals  (Fig.  119). 

The  practical  significance  of  this  bone  is  evident  from  a  case 
described  by  Wilmans,  of  Hamburg.  A  labourer  claimed  that  he 
was  injured  by  an  iron  bar  on  January  20,  1897,  but  was  able  to 
work  during  the  whole  day.  On  the  following  day  he  called  on  Dr. 
Wilmans,  complaining  of  intense  pain  at  his  internal  malleolus. 
He  limped  and  asserted  his  inability  to  work.  Wilmans  found  a 
slight  swelling  below  the  right  internal  malleolus.  Ecchymosis  of 
the  skin  being  absent,  the  swelling  was  attributed  to  the  presence 
of  a  considerable  degree  of  talipes,  from  which  the  labourer  suf- 
fered at  the  same  time.  The  leg  was  elevated  and  fomentations 
were  applied  for  several  days.  The  patient  still  complaining  of 
great  pain,  it  was  decided  to  transfer  him  to  a  hospital  for  obser- 
vation. When  discharged,  after  several  weeks  of  treatment,  the' 
labourer  made  an  effort  to  resume  work,  but  at  once  declared  that 
he  was  unable  to  keep  it  up.  He  was  therefore  admitted  to  an- 
other hospital,  where  he  repeated  this  manoeuvre  several  times 
during  a  period  of  six  months.  Finally,  he  claimed  damages  for 
having  been  crippled  by  the  injury  sustained  on  January  20,  1897; 
but  in  view  of  the  negative  objective  condition  found  by  Dr.  Wil- 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  345 

mans,  the  society  decided  not  to  granl  any  claim.  The  conse- 
quence was  that  the  man  was  transferred  to  the  surgical  division 
of  a  third  hospital  for  further  observation.  There  he  complained 
that  he  had  continuous  pains  below  the  righl  external  malleolus, 
even  while  in  the  recumbeni  posit  ion.  The  pain  increased  during 
walking  or  sitting.  Stepping  on  the  righl  heel  he  also  declared 
to  be  impossible.  By  distracting  his  attention,  however,  it  was  no- 
ticed that  he  could  stand  well  on  his  heel,  and  he  would  doubt- 
less have  been  declared  a  malingerer  had  not  the  X-rays  come  to 
his  rescue — at  least  temporarily.  A  skiagraph  showed  a  hone- 
fragment  at  the  junction  of  the  astragalus  with  the  posterior  sur- 
face of  the  calcaneum.  On  the  strength  of  this  skiagraphic 
"proof"  Dr.  Wilmans,  although  still  mistrusting,  was  forced  to 
modify  his  original  opinion  and  certified  that  the  patient  suffered 
from  "fracture  of  the  astragalus,  in  consequence  of  which  lie  was 
damaged  for  life."  The  labourer  therefore  received  an  annuity  of 
30  per  cent,  in  proportion  to  the  estimated  curtailing  of  his 
wages.  Soon  afterward  the  labourer  was  seen  by  Dr.  Wilmans  car- 
rying a  heavy  load  without  any  apparent  pain,  while  formerly  he 
had  claimed  to  be  unable  to  walk  without  a  cane  or  crutch.  Now 
Dr.  Wilmans  insisted  upon  a  second  irradiation,  this  time  also  skia- 
graphing  the  uninjured  left  foot.  The  skiagraph  showed  the  "  sev- 
ered bone-fragment,'"  which  had  first  been  regarded  as  a  sesamoid 
of  the  musculus  flexor  longus  hallucius.  but  which  now  was  recog- 
nised as  a  normal  os  intermedium  cruris.  The  society,  of  course, 
refused  the  annuity,  and  the  German  supreme  assurance  court,  to 
which  the  man  had  appealed,  not  only  sustained  the  verdict  of  the 
society,  but  also  decided  that  the  labourer  must  return  the  annuity 
which  he  had  unjustifiably  enjoyed  for  eighteen  months. 

In  this  case  the  Rontgen  rays  were  very  near  becoming — the 
contrary  of  what  they  are  expected  to  be — a  protector  of  dishon- 
esty. But  the  fault  would  have  lain  with  the  insufficient  anatom- 
ical knowledge  and  not  with  the  rays  themselves,  which  repro- 
duced the  condition  exactly  as  it  was.  The  repetition  of  such 
cases,  however,  is  highly  improbable. 

A  complicated  medico-legal  question  will  arise  when  chronic 
diseases  develop  after  an  injury.  Osteitis,  arthritis  deformans, 
and  even  malignant  growths  are  not  infrequently  observed  in  this 
connection.  If  such  injuries  are  sustained  in  factories,  a  suit 
for   negligence    is    generally   brought    against    the    owner.      The 


346  THE    KONTGEN    EAYS 

amount  of  damages,  of  course,  depends  largely  upon  the  duration 
of  the  healing  process  and  the  degree  of  functional  disturbance. 
This  will  vary  greatly,  as  from  a  case  of  simple  fracture,  which 
may  be  accurately  united  in  a  few  weeks,  to  an  injury  followed  by 
the  development  of  a  malignant  growth,  which  will  finally  cause 
the  death  of  the  patient. 

Fig.  205,  for  instance,  illustrates  the  case  of  a  labourer  fifty 
years  old,  who  sustained  an  injury  of  his  elbow  eleven  years  ago 
(compare  page  209).  He  reported  that  recovery  took  place  after 
months,  and  that  the  elbow  had  remained  stiff  ever  since.  During 
the  last  few  years  inflammatory  signs  had  manifested  themselves, 
which  were  regarded  as  rheumatic.  No  other  joints  were  involved. 
Since  then  he  also  had  repeated  attacks  of  pain  in  the  elbow-joint. 

When  first  examining  the  patient  it  was  found  that  the 
elbow  was  very  much  thickened  and  fixed  in  a  sharp  angle.  Pres- 
sure below  the  external  condyle  caused  intense  pain.  Crepitus,  so 
often  found  in  old  arthritic  processes,  could  not  be  produced  in 
this  instance,  as  the  joint  permitted  no  motion  at  all.  There  were 
no  indications  of  tuberculosis,  syphilis,  or  gonorrhoea. 

The  skiagraph  revealed  the  presence  of  malunion  (sideways 
displacement)  of  the  coronoid  process  of  the  ulna.  This  probably 
had  given  the  first  impetus  for  the  development  of  the  arthritis 
deformans,  which  is  especially  well  marked  in  the  external  con- 
dyle of  the  humerus.  The  left  condyle  showed  synostosis  with  the 
olecranon.  Eemoval  of  the  projecting  fragment  by  the  chisel, 
separation  of  adhesions,  and  the  partial  resection  of  the  external 
condyle,  the  seat  of  predilection  for  the  acute  attacks,  were  advised 
as  therapeutic  means. 

It  was  promised  the  labourer,  who  sustained  his  fracture  in 
a  factory,  and  who  did  not  show  any  signs  of  ill  health  before,  that 
he  could  use  his  arm  again  a  few  weeks  after  the  accident.  After 
ten  weeks  he  was  able  to  resume  light  work;  then  the  swelling  be- 
came gradually  worse,  and  the  diagnosis  of  arthritis  was  made. 
He  has  remained  a  cripple  ever  since,  and  his  wages  were  cut  down 
considerably.  He  might  have  claimed  damages,  but  in  view  of  the 
presence  of  arthritis  he  realized  the  difficulty  to  prove  that  there 
was  a  fracture  originally.  The  Rontgen  rays  would  have  furnished 
this  proof  for  him. 

The  development  of  malignant  growths  after  an  injury  is  illus- 
trated by  skiagraphs  No.  220  and  221,  which  show  the  faint  out- 


MEDICO-LEGAL    ASPECTS    OF    X-EAYS  347 

lines  of  bone-shell  in  the  soft  myelosarcoma  of  a  woman  of  twenty- 
eight  years,  who  had  fallen  on  her  hand  in  dorsal  flexion  (compare 
page  287).  The  swelling  resulting  from  it  gave  the  impression  that 
a  fracture  of  the  carpal  cod  of  the  radius  was  sustained.  Three 
months  after  the  injury,  when  the  author  first  saw  the  patient,  he 
noticed  a  small  deformity,  just  as  it  is  observed  in  badly  united 
fracture  of  the  carpal  end  of  the  radius;  but  the  consistency  of  the 
epiphyseal  end  was  soft.  The  skiagraph  failed  to  show  the  evidence 
of  bone  tissue,  only  one  small  remnant  being  left  at  the  outer  aspect 
of  the  radius.  Resection  was  advised  ;  but  before  the  patient  sub- 
mitted to  it  another  month  elapsed,  during  which  time  the  neo- 
plasm had  grown  to  twice  its  size.  The  result  was  reported  fair 
eighteen  months  after  the  operation.  But  the  chances  for  a  per- 
manent recovery  are  poor.  (See  The  Differentiation  between  In- 
flammatory Processes  and  Neoplasms.  Annals  of  Surgery,  Decem- 
ber, 1901.) 

It  is  not  always  possible  to  show  the  evidence  of  a  fracture  as 
long  as  twelve  years  after  its  occurrence,  as  in  the  case  of  the 
labourer  described,  in  which  the  displacement  proved  that  there 
was  fracture  of  the  coronoid  process  of  the  ulna.  The  older  the 
fracture,  the  less  the  fracture-line  will  appear.  In  case  of  the 
entire  absence  cf  displacement  it  is  only  a  very  distinct  skiagraph 
that  shows  the  line  clearly.  It  is  natural  that  in  such  cases  there 
is  no  skiagraphic  evidence  after  recovery — that  is,  from  four  to 
ten  weeks,  according  to  the  type  of  the  fracture.  Should  a  jury 
in  such  an  event  doubt  that  there  was  a  fracture,  a  skiagraph 
taken  after  such  a  period  will  show  a  negative  result,  although  there 
surely  was  a  fracture.  At  one  of  his  demonstrations  the  author 
showed  a  boy  whose  fracture  of  the  femur  could  not  be  shown 
by  a  very  distinct  skiagraph  taken  two  months  after  the  injury, 
because  there  was  a  faultless  union.  Had  the  thigh  not  been  skia- 
graphed  shortly  after  the  injury,  no  evidence  of  the  fracture  could 
have  been  obtained  subsequently. 

Fig.  1-17  illustrates  the  case  of  the  girl  who  sustained  a  fissure 
of  the  head  of  the  radius  followed  by  considerable  functional  dis- 
turbance. Another  perfect  skiagraph,  taken  four  weeks  after  the 
accident,  showed  ideal  union,  so  that  no  fissure-line  could  be  rec- 
ognised. This  also  shows  how  quickly  the  evidence  of  the  pres- 
ence of  a  fissure-line  becomes  lost  if  there  be  perfect  approximation 
(compare  page  206). 


348 


THE    RONTGEN    RAYS 


This  experience  suggests  that  a  mediocre  or  even  indistinct 
plate  should  never  be  admitted  into  court.  It  has  repeatedly 
occurred  to  the  author  that  he  was  not  able  to  discover  a  fissure 
or  fracture  in  a  mediocre  skiagraph,  which  appeared  well  marked 
in  a  faultless  one.  Such  facts  explain  very  well  why  some  sur- 
geons have  disputed  the  reliability  of  other  fellow-observers.  Dr. 
A,  for  instance,  insisting,  and  properly,  upon  his  own  diagnosis, 


Ftg.  258. — Fracture   of   Radial   Diaphysis,    Overlooked  first   by   Fluoro- 
scopic Examination  as  well  as  in  a  Mediocre  Skiagraph. 


while  Dr.  B,  with  his  poor  skiagraph,  ridicules  Dr.  A's  imagina- 
tion, and  sneeringly  asserts  that  he  could  find  no  fissure-line.  Of 
course,  Dr.  B's  opinion  is  thoroughly  honest,  but  absolutely 
erroneous,  nevertheless.  It  should  also  be  considered  that  during 
the  first  days  of  the  injury  the  presence  of  a  fissure  is  more  easily 
overlooked  than  later,  when  callus-formation  begins. 

But  that  even  in  a  fairly  good  skiagraph  a  fracture,  followed 
by  no  displacement,  can  be  overlooked,  is  illustrated  by  Fig. 
258,  which  illustrates  the  case  of  a  bricklayer  who  sustained  a 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  349 

fracture  of  the  middle  of  the  radius  three  weeks  ago,  a  heavy  brick 

having  fallen  on  his  outstretched  arm.  He  had  great  pain  at  the 
seat  of  the  fracture,  his  hand  was  slightly  swollen,  and  there  was 
disturbance  of  function.  Crepitus  could  no!  be  elicited.  A  fluoro- 
scopic examination  made  by  the  author  as  well  as  by  a  number  of 
physicians  revealed  nothing  abnormal.  A  fairly  good  skiagraph 
made  at  the  time  proved  negative.  Another  one.  taken  in  the 
opposite  direction,  gave  the  same  result.  But  the  suspicion  that 
a  fracture  was  present  was  so  strong  that  a  third  exposure  was 
made,  this  time  long  enough  to  bring  out  the  bone-texture,  the  re- 
sult of  which  was  the  faint  representation  of  an  oblique  fracture- 
line  at  the  point  of  tenderness.  A  fourth  skiagraph,  taken  from 
the  extensor  side,  revealed  the  fracture-line  still  more  distinctly. 

When  in  this  case  the  author  was  at  first  unable  to  represent 
the  fracture,  some  of  the  physicians  present  suggested  that  this 
was  a  proof  of  the  integrity  of  the  bones,  and  that  the  soft  tissues, 
perhaps  a  nerve,  were  injured.  But,  as  a  rule,  injuries  of  this 
kind  are  only  found  in  nerves,  when  there  is  a  synchronous  injury 
of  the  trauma  of  the  soft  tissues.  In  a  case  of  this  kind  a  differ- 
ence of  opinion  between  experts  may  happen  in  court,  and  the 
patient  may  become  the  victim  of  an  imperfect  technique.' 

A  counterpart  to  this  case  is  the  one  of  a  boy  who  was  under 
the  author's  treatment  after  extirpation  of  his  cervical  glands, 
and  who  sustained  a  contusion  of  the  forearm,  while  the  author 
happened  to  be  absent  from  the  city.  So  he  was  referred  to  a 
brother  physician,  who  was  supposed  to  be  an  expert  in  Bontgen 
science.  Belying  entirely  upon  the  fluoroscopic  screen,  he  claimed 
to  have  seen  the  fracture-line  and  declared  a  photograph  to  be  un- 
necessary. A  plaster-of-Paris  dressing,  extending  over  wrist  and 
elbow,  was  applied  in  consequence.  A  few  days  later,  when  the 
patient  was  referred  back  to  the  author,  he  made  a  fluoroscopic 
examination  of  the  arm,  and  as  he  could  see  no  fracture-line  he 
took  a  skiagraph  through  the  plaster-of-Paris  dressing.  No  evi- 
dence of  fracture  being  found,  the  plaster-of-Paris  dressing  was 
removed,  although  the  bones  presented  themselves  distinctly.  This 
third  skiagraph  proved  that  there  was  absolutely  no  fracture,  a 
fact  which  was  corroborated  by  the  perfect  function  of  the  arm. 

These  two  cases  afford  further  support  for  the  demand  that 
only  faultless  skiagraphs  should  be  admitted  as  evidence  in  court. 

While  we  can  readily  see  that  a  skiagraph  furnishes  the  most 


350 


THE    RONTGEN    RAYS 


convincing  proof  of  the  extent  of  the  bone  injuries,  it  does  not 
show  the  injuries  of  the  soft  tissues,  at  least  not  directly.  There- 
fore a  skiagraph  alone  is  not  conclusive  for  the  purpose  of  esti- 


FlG.    259.—  FRACTURE   OF   TlHIA.      TlIIS   SAME  AS   FlG.    260.      LATERAL   EXPOSURE. 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  351 

mating  the  degree  of  functional  disability.  A  non-medical  skiag- 
rapher  will,  therefore,  never  he  able  to  give  expert  testimony  in 
any  case  of  injury.  If  there  is  only  one  skiagraph  taken  the  injury 
may  appear  at  its  worst,  and  vice  versa.  So  a  skiagraph  may  show 
a  considerable  degree  of  bony  deformity,  and  still  the  fund  ion 
may  be  but  little  disturbed.  Even  fair  results  show,  especially 
when  displacement  of  the  fragments  or  other  unfortunate  compli- 
cations were  present,  no  ideal  union,  and  still  the  function  may 
be  good.  An  unscrupulous  patient,  who  secures  possession  of  a 
skiagraph  of  his  own  case,  which  shows  considerable  deformity, 
may  strongly  appeal  to  a  jury  on  the  strength  of  this  deformity, 
especially  if  he  succeeds  in  simulating  great  disturbance  of  func- 
tion. On  the  other  hand,  there  may  be  but  little  evidence  of  bone 
injury  on  the  skiagraph,  but  there  may  be  severe  impairment  of 
function  on  account  of  the  injury  of  the  soft  tissues  (circulatory, 
trophic,  or  inflammatory  disturbances),  which  can  be  produced 
only  faintly,  if  at  all.  Thus  we  see  that  in  a  given  case  the  skia- 
graph must  be  considered  in  connection  with  all  the  clinical  symp- 
toms, and  this  can,  of  course,  only  be  done  by  an  experienced 
medical  expert.  As  alluded  to,  a  thorough  anatomical  knowledge 
is  required.  But  it  is  also  necessary  to  know  the  different  modes 
of  delineations  and  various  projection  planes. 

The  history  revealed  that  the  patient,  a  boy  four  years  of  age, 
fell  against  an  iron  bar  while  playing.  Being  unable  to  rise  again, 
he  was  taken  up  and  carried  to  St.  Mark's  Hospital,  where,  in  the 
first  instance,  moderate  pain  was  noted  besides  the  functional  dis- 
turbance in  the  left  leg.  There  was  neither  any  difference  in 
level  nor  any  other  deformity,  nor  any  shortening,  nor  the  equinous 
position,  but  only  a  very  moderate  and  uniform  swelling  of  the 
leg.  Abnormal  mobility  and  crepitus  could  be  produced  only  by 
very  rough  manipulations. 

On  the  day  following  the  injury  two  skiagraphs  were  taken  in 
different  positions,  one  of  them  on  the  dorsal  and  the  other  in  the 
lateral  position.  The  one,  made  by  antero-posterior  irradiation, 
the  platinum  disk  of  the  tube  being  perpendicular  to  the  anterior 
surface  of  the  leg,  did  not  show  any  indications  of  a  fracture-line 
(see  illustration  in  New  York  Medical  Journal,  January  6,  1900), 
while  the  other,  obtained  by  lateral  irradiation,  shows  the  fracture 
distinctly  (Fig.  259).  A  third  exposure,  made  on  the  fifth  day 
after  the  injury,  in  antero-posterior  projection,  but  very  slightly 


352  THE    RONTGEN    RAYS 

bent  laterally,  also  shows  the  fracture-line  beyond  doubt  (Fig. 
260). 

The  fracture  presented  the  typical  oblique  type  in  the  middle 
of  the  tibia  (fracture  a  la  bee  de  pate),  the  fracture-line  running 
from  below  anteriorly  to  above  posteriori}^,  and  the  upper  taper- 
ing fragment  overlapping  the  lower  end.  No  lateral  displace- 
ment having  been  present,  it  will  be  understood  why  the  rays, 
reaching  the  long  axis  of  the  tibia  in  a  perpendicular  direction, 
did  not  show  the  fracture-line.  A  very  slight  change  in  the  posi- 
tion, where  the  inclination  towards  the  fibular  direction  amounted 
to  less  than  a  millimetre,  brought  out  the  fracture  distinctly.  If 
this  skiagraph,  however,  is  not  studied  very  carefully,  the  transpar- 
ency of  the  thinnest  portion  of  the  fragment  might  create  the 
erroneous  impression  that  the  lower  portion  overhung  the  upper 
one. 

Now,  if,  as  is  usually  done,  a  skiagraph  had  been  taken  in  the 
antero-posterior  direction  only,  and  if  the  manipulations  made 
during  the  first  examination  had  been  carried  out  as  gently  as 
they  properly  should  be,  the  fracture  might  have  been  overlooked 
entirely.  And  if,  in  view  of  the  local  pain  and  tenderness,  the 
swelling  and  the  functional  disturbance,  the  possibility  of  a  frac- 
ture had  been  seriously  considered,  the  first  skiagraph  might  have 
silenced  the  uneasy  conscience. 

This  experience  also  teaches  the  necessity  of  always  taking  at 
least  two  skiagraphs  in  different  positions  in  all  cases  of  sus- 
pected fracture. 

If  this  case  were  brought  before  a  jury,  an  expert  might  there, 
on  the  strength  of  the  first  skiagraph  taken  in  the  antero-posterior 
projection,  have  testified,  in  good  faith,  that  there  was  no  fracture. 
With  the  diaphragm,  however,  even  in  this  position,  at  least  a  faint 
indication  of  the  fracture-line  is  shown. 

In  a  case  of  osteo-epiphyseal  separation  of  the  radius  in  a  lad 
of  sixteen  years,  who  had  fallen  from  a  stone  staircase,  the  first 
skiagraph  gave  the  impression  of  normal,  non-ossified  epiphyseal 
ends.  A  second  skiagraph,  taken  with  the  ulnar  margin  of  the 
hand  slightly  lifted,  showed  the  presence  of  the  fracture-line  be- 
yond doubt,  while  the  third  skiagraph,  taken  in  the  lateral  position, 
markedly  illustrated  the  displacement  of  the  fragments.  (Com- 
pare Fig.  162.) 

These  cases  are  another  proof  of  the  absolute  need,  as  stated 


MEDICO-LEGAL    ASPECTS    OF    X  -RAYS  353 

on  previous  occasion,  of  taking  ;ii  Leasl  two  exposures  in  differenl 
positions  in  all  fracture  cases.     In  joint  injuries  ii  is  often  neces- 


Fig.  260.— Fracture  a  la  bec  de  Flute  of  the  Middle  of  the  Tibia. 
(Compare  Fig.  259.     Anterior  Exposure  ) 


sary  to  make  a  skiagraph  of  the  healthy  joint  at  the  opposite  side 
at  the  same  time,  in  the  same  position,  and  in  the  same  projection. 
24 


354  THE    EONTGEN    EAYS 

Sometimes  it  is  also  advisable  to  compare  a  normal  skeleton  with 
a  skiagraph,  since  some  pathological  conditions  like  rachitis, 
syphilis,  etc.,  influence  the  outlines  of  the  bones  and  may  deceiv- 
ingly be  supposed  to  represent  a  portion  of  an  injury.  The  fact 
that  in  children  the  epiphyseal  tissues  are  not  sufficiently  ossified 
to  produce  a  shadow  on  the  plate  has  caused  many  but  unjustifi- 
ble  errors  at  the  early  Eontgen  era. 

In  many  fractures  the  destruction  was  so  extensive  that  a  good 
result  could  not  be  expected  under  any  circumstances.  Then 
the  patient  may  be  tempted  not  only  to  claim  damages  from  his 
employer,  but  also  from  his  physician.  In  such  a  ease,  a  skia- 
graph taken  as  early  after  the  accident  as  possible  will  be  the  best 
protection  for  the  physician.  It  would  be  a  document  showing 
that  the  physician  knew  well  the  serious  nature  of  the  injury. 
The  skiagraph  Fig.  261,  for  instance,  illustrates  a  multiple  frac- 
ture of  the  elbow.  Splinters  of  bone  are  scattered,  and  are  shown 
embedded  in  the  soft  tissues.  None  but  a  fool  would,  on  the 
strength  of  this  skiagraph,  have  expected  the  surgeon  to  restore 
the  lower  end  of  the  humerus,  which  was  almost  completely  shat- 
tered, to  a  normal  condition.  Or  if  a  deformity  is  caused  by  ex- 
cessive callus-formation,  the  skiagraph  will  be  the  surgeon's  advo- 
cate. In  one  case  considerable  deformity  of  the  wrist  was  present, 
which  caused  disturbance  of  function.  The  skiagraph  showed  the 
fragments  in  splendid  apposition,  proving  that  the  deformity  was 
produced  by  excessive  callus-formation,  for  which,  of  course, 
nobody  can  be  made  responsible.  The  patient  who  accused  his 
physician  of  malpractice  could,  when  he  saw  the  skiagraph,  be 
easily  convinced  by  the  author  that  he  had  done  great  injustice  to 
his  physician. 

In  the  case  of  the  girl,  illustrated  by  Figs.  239,  240,  and  241,  a 
diagnosis  without  the  Eontgen  rays  was  simply  impossible, and  with- 
out the  diagnosis  the  patient  would  surely  have  been  crippled.  It 
was  not  until  weeks  had  passed  and  the  swelling  had  subsided  that 
the  author  was  able  to  grasp  the  radial  fragment,  which  is  of  such 
great  importance  in  view  of  its  joint  surface.  Would  the  court 
have  the  right  to  censure  the  physician  if  he  had  not  advised  skiag- 
raphy ?  If  litigation  ensued,  would  the  other  party  have  had  the 
right  from  the  beginning  to  insist  that  a  skiagraph  be  taken? 
And  if  we  had  not  succeeded  in  reducing  the  fragment,  would  we 
have  been  criticised? 


MEDICO  LEGAL  ASPECTS  OF  X  RAYS 


355 


A  delicate  medico-lega]  question  is:  Wha1  secures  the  identity 
of  the  patient  who  is  skiagraphed ?  Is  it  sufficienl  thai  he  signs 
his  name  on  the  envelope  of  the  plate  with  a  pencil  containing  im- 
permeable substances,  so  that  ln's  signature  is  photographed  together 
willi  the  limb,  or  is  il  necessary  to  have  a  witness  present,  or  both? 

This  brings  as  in  touch  with  another  question,  which  is  a  burn- 
ing one  in  the  full  souse  of  the  word:  [s  the  physician  responsible 
for  an  injury  burn,  caused  by  the  peculiar  influence  of  the  rays, 
if  they  are  \\>c(\  for  diagnostic  purposes?  As  described  in  the  fol- 
lowing chapter,  it  seems  that  in  some  individuals  a  susceptibility 


Fig.  261. — Shattehed  Elbow. 


exists  which  can  be  compared  with  the  so-called  iodoform  idiosyn- 
crasy. This  susceptibility  cannot  be  recognised  except  after  the 
burn  has  established  itself,  when,  in  other  words,  it  will  be  too 
late  for  prophylaxis.  All  we  know  is  that  blonde  individuals  are 
more  susceptible  than  others.  There  are  no  means  at  all  which 
protect  the  body  from  this  except  by  a  hasty  examination.  Since 
the  time  of  exposure  has,  thanks  to  our  improved  apparatus,  been 
considerably  diminished,  the  danger  of  burning  the  patient  during 
a  thorough  diagnostic  exposure  is  extremely  small. 

As  the  Rontgen  rays  have  also  shown  therapeutic  properties, 
this  question  has  reached  a  new  phase.  In  order  to  exert  a  curative 
influence  frequent  and  powerful  exposures  are  required,  and  conse- 


356  THE    RONTGEN    RAYS 

quently  the  patient  must,  in  the  end,  risk  burning,  as  described  in 
Chapter  XVIII.  In  some  instances,  a  protection  can,  especially 
in  non-malignant  skin  diseases,  be  obtained  by  lead  masks.  But  if 
malignant  growths  like  cancer  or  sarcoma  are  treated,  too  much 
irradiation  can  hardly  be  done.  In  view  of  the  fact  that  the  cancer 
cells  are  not  confined  to  the  growth  itself,  but  are  also  found  in 
the  adjacent  tissues,  it  is  necessary  to  irradiate  as  large  an  area 
as  possible.  Where  ulcerations  already  exist,  as  often  happens 
in  carcinoma;,  and  where  new  ulcerations  as  well  as  inflammatory 
processes  may  originate  every  day,  an  unscrupulous  patient  may 
claim  that  they  were  caused  by  the  injudicious  use  of  the  rays. 
Can  a  physician  protect  himself  against  such  allegations  by  simply 
stating  that  the  risks  of  the  Rontgen-ray  therapy  were  explained 
to  him?  or  are  further  ceremonies  required?  Numerous  medico- 
legal questions  have  come  up  with  this  wonderful  discovery,  which 
have  not  yet  been  satisfactorily  answered. 

In  severe  cases  of  dermatitis,  especially  if  there  are  necrotic 
areas,  it  appears  to  be  natural  that  the  patient  is  only  too  much 
inclined  to  blame  his  examiner.  Whether  the  operator  was  negli- 
gent or  not  seems  to  be  immaterial  to  the  great  majority  of  the  in- 
jured; all  they  see  are  the  sad  consequences.  In  the  court  cases  in 
which  the  author  was  called  up  as  an  expert,  he  was  shocked  by 
the  unjust  if,  indeed,  he  may  not  say  the  felonious  attitude  of  the 
plaintiffs.  Although  with  our  present  means  it  should  not  appear 
very  difficult  to  settle  the  question  whether  the  physician  has  com- 
mitted any  negligence  or  whether  he  or  his  patient  is  the  victim 
of  unfortunate  circumstances,  there  is  hardly  any  subject  in  the 
wide  field  of  medical  jurisprudence  where  the  juries,  judges,  and 
experts  disagree  as  much  as  in  this.  The  decisions  of  the  courts  in 
this  country  as  well  as  in  Germany,  England,  France,  and  the 
Netherlands  illustrate  a  most  deplorable  state  of  affairs  in  this 
matter.  French  courts  have  excelled  in  decisions  against  physi- 
cians, especially  in  all  cases  where  the  corpus  delicti  had  consisted 
in  injury  to  the  complexion  of  the  fair  sex. 

Some  time  ago  in  New  York  State  a  suit  was  dismissed  which 
had  been  brought  against  a  dentist  of  good  repute  who  had  sus- 
pected the  neuralgia  of  his  patient,  a  young  lady,  to  be  caused  by  a 
foreign  body  in  her  jaw.  The  dentist  very  properly  recommended 
that  a  Rontgen-ray  photograph  should  be  taken  in  order  to  verify 
his  suspicion.    At  that  time  very  few  physicians  were  familiar  with 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  357 

the  technic  of  the  new  method,  wherefore  an  electrician  was  rec- 
ommended who  had  the  reputation  then  of  being  an  "  X-ray 
specialist."  The  result  after  repeated  exposures  was  an  extensive 
burn  of  the  third  degree  around  the  neck  of  the  patient.  The 
patient  claimed  that  "  a  million  volts  of  electricity  were  used/' 
undoubtedly  a  somewhat  excessive  voltage,  and  one  which  should 
justify  the  large  amount  of  damages  demanded.  The  court  upheld 
the  defendant's  contention,  that  the  patient  had  voluntarily  sub- 
mitted to  the  Eontgen  ray  exposures  upon  the  advice  of  the  dentist, 
and  as  he  had  not  administered  the  treatment,  he  was  not  liable. 
The  dentist,  in  fact,  would  deserve  high  praise  in  seeking  the  best 
information  for  the  cause  of  this  patient's  ailment.  The  question 
of  the  responsibility  of  the  electrician  is  still  left  open. 

In  this  country  several  cases  are  on  record  in  which  burns 
were  caused  by  searching  for  renal  stones,  the  examination  being 
done  by  experienced  physicians.  Only  in  one  case,  as  far  as  the 
author  knows,  the  patient  commenced  suit  against  one  of  the 
best  experts  in  Eontgengraphy.  The  suit  was  dismissed  by  the 
judge. 

The  suit  against  Professor  Hoffa,  of  Berlin,  the  famous  ortho- 
pedist, became  widely  known,  not  only  because  of  the  prominence 
of  the  defendant,  but  more  so  for  the  complicated  etiology  of  the 
injury.  The  patient  suffered  from  ankylosis  of  his  hip,  presum- 
ably after  coxitis,  for  which  he  was  treated  by  the  Eontgen  rays 
under  the  supervision  of  an  "  X-ray  specialist."  Altogether  he 
was  exposed  36  times.  No  change  for  the  better  taking  place  the 
patient  consulted  Professor  Hoffa,  who  advised  a  diagnostic  ex- 
posure in  order  to  ascertain  the  condition  of  the  hip-joint.  The 
distance  of  the  tube  from  the  abdominal  integument  was  30  cm., 
the  length  of  exposure  25  minutes.  Ten  days  later  extensive  der- 
matitis set  in,  which  induced  the  patient  to  bring  charges  of  crim- 
inal negligence  in  the  treatment.  Professor  Hoffa,  in  defense, 
claimed  that  the  exposure  was  made  according  to  the  principles 
adopted  by  the  medical  profession,  and  that  furthermore  the  sen- 
sitiveness of  the  skin  was  increased  by  the  previous  irradiations. 
The  district  attorney,  after  having  called  upon  an  expert,  who  sus- 
tained Professor  Hoffa,  dismissed  the  claim. 

Nowadays,  by  our  greatly  improved  means,  Hoffa  would  not 
have  burned  his  patient,  even  in  spite  of  the  preceding  irritation, 
because  he  would  not  have  exposed  for  25  minutes.    It  is  only  a 


358  THE    EONTGEN    KAYS 

few  months  ago  that  the  author  had  an  opportunity  to  see  Pro- 
fessor Hoffa  take  a  beautiful  Eontgen  plate  of  a  hip  in  three  min- 
utes. 

We  may  safely  expect  that  damage  suits  for  Bontgen-ray  burns, 
caused  during  diagnostic  exposures,  will  become  very  infrequent. 
But  with  the  employment  of  the  Eontgen  rays  for  therapeutic  pur- 
poses this  question  of  injuries  has  entered  into  a  new  phase.  Burns 
have  now  become  a  rather  common  accident.  In  several  instances 
suits  were  brought  against  physicians,  especially  on  the  ground 
that  they  did  not  use  the  necessary  means  of  protection.  In  most 
of  these  instances  the  severe  character  of  the  diseases  demanded  a 
severe  treatment,  so  that  burning  had  to  be  risked.  This  fact  alone 
is  sufficient  proof  of  the  perfidious  nature  of  the  suits.  In  cases 
where  only  cosmetic  considerations  are  concerned,  such  risky 
therapy  is  unnecessary  of  course,  the  diseased  area  alone  requiring 
irradiation,  and  the  healthy  vicinity  demanding  protection.  If  in 
cases  of  this  kind  the  patient  is  promised  that  no  burning  could 
take  place,  he  feels  justified  to  find  fault  with  his  physician  when 
the  promise  is  not  fulfilled,  when,  in  other  words,  dermatitis,  fol- 
lowed by  ugly  cicatrization,  is  exchanged  for  a  few  superfluous 
hairs. 

An  illustration  of  the  deplorable  consequences  of  omission  is 
the  suit  brought  against  a  prominent  physician  in  Germany,  who 
treated  a  lady  for  hypertrichosis  of  the  chin  for  several  months. 
After  repeated  reactions  of  a  slight  nature  were  observed,  the  face 
showed  signs  of  dermatitis  of  the  second  degree  while  the  anterior 
aspect  of  the  chest  developed  a  burn  of  the  third.  After  five  months 
cicatrization  had  taken  place  in  the  face.  But  the  chest  still 
showed  a  large  ulceration.  At  that  time  the  patient  brought 
charges  against  the  physician  for  criminal  negligence. 

The  court  called  upon  various  experts.  One  was  the  official 
"  Court  physician,"  who  admitted  that  he  did  not  understand  any- 
thing of  the  Eontgen  rays,  but,  strange  to  say,  gave  his  official 
opinion  nevertheless. 

Besides  this  the  expert  testimony  of  the  "  Governmental  medi- 
cal board  of  the  province  "  was  obtained.  None  of  these  testimonies 
was  favorable  for  the  defendant.  The  third  was  that  of  the  "  Eoyal 
medical  deputation "  of  Berlin,  which  was  in  favor  of  the  de- 
fendant. The  plaintiff  recovered  judgment  to  the  amount  of  $75. 
The  points  of  the  complaint  were,  first,  the  insufficient  informa- 


MEDICO-LEGAL    ASPECTS    OF    X-RAYS  :m 

lion  of  the  patient  in  regard  to  the  possible  consequences  of  the 
treatment;  second,  the  insufficient  protection  of  those  areas  which 

did  not  require  irradiation:  third,  the  continuation  of  the  treat- 
ment after  redness  had  appeared. 

The  court  disregarded  the  first  two  points  but  sustained  the 
third,  viz.,  negligence.  This  judgment  is  based  on  an  error.  If  the 
court  had  held  that  the  chest  should  have  been  protected  it  might 
have  been  more  correct,  but  it  could  not  have  found  fault  with  the 
continuation  of  the  treatment  after  slight  reaction  had  shown 
itself. 

How  far  the  beneficial  influence  of  inflammation  produced  by 
the  Eontgen  rays  goes  is  also  illustrated  by  Figs.  266,  268,  271 
and  274. 

As  to  the  etiology  of  Rontgen-ray  dermatitis,  its  course  and  sig- 
nificance, the  reader  is  referred  to  the  following  chapters.  The 
proper  means  of  protection  are  also  discussed  there. 

In  the  meanwhile  another  miraculous  phenomenon  makes  its 
appearance  on  the  medical  horizon.  Little  as  we  know  of  the 
practical  utilization  of  radium,  yet  it  marks  a  new  era  in  electrical 
science.  Its  influence  upon  diseased  tissue  is  undisputed,  and  con- 
sequently we  shall  soon  hear  of  accidents  caused  by  its  therapeutic 
use.     (Further  particulars  are  found  in  Chapter  XX.) 


SECTION   III 

EFFECTS  OF  THE  RONTGEN  RAYS 


CHAPTER    XVIII 
RONTGEN  THERAPY 

Physiological. — Soon  after  the  discovery  of  the  rays  it  was 
found  that  they  had  a  marked  influence  on  the  protoplasm  of  the 
irradiated  cell.  Especially  the  peculiar  changes  which  manifested 
themselves  in  the  skin  of  persons  who  were  exposed  to  the  rays  for  a 
long  period,  called  attention  to  this  fact,  which  suggested  that  they 
were  due  to  a  specific  influence.  To  define  their  influence  the 
various  phenomena  emanating  from  the  tube  must  be  known.  In 
the  first  place,  it  must  be  considered  that  there  are  different  kinds 
of  rays  generated  in  the  vacuum  as  well  as  at  the  surface  of  the  tube 
— namely,  Eontgen,  cathode,  ultra-violet  rays,  and  those  of  an  un- 
known character.  There  are  also  spark  and  brush  discharges, 
and  electric  and  electrodynamic  waves. 

The  heat  and  ozone  which  are  produced  at  the  same  time 
apparently  do  not  participate  in  that  specific  influence.  The  ultra- 
violet rays  cannot  be  of  any  practical  importance,  since  they  are 
absorbed  by  the  glass  of  the  tubal  wall,  after  being  generated  in 
the  vacuum. 

The  cathode  rays  show  similar  conditions,  inasmuch  as  they 
permeate  thin  layers  of  aluminum  only  and  are  extensively  ab- 
sorbed by  glass. 

Therapeutic  Effects. — The  fact  that  the  wall  of  the  tube  becomes 
blackened  after  long  use  gave  the  impetus  to  the  theory  of  the 
direct  bombardment  with  particles  from  the  electrodes.  But  it  has 
neither  been  proved  that  they  ever  passed  the  tube,  nor  has  the 
microscopical  examination  of  the  injured  integumental  area  shown 
any  evidence  of  the  presence  of  such  elements. 
360 


RONTGEN    THERAPY  361 

Direct  electric  discharges  cause  an  influence  on  the  skin  simi- 
lar to  that  produced  by  the  Rontgen  rays.  An  exposure  to  the 
brush  discharge  of  a  generator  capable  of  a  spark  length  of  two 
inches  may  cause  a  burn.  But  that  electricity  alone  could  not 
cause  that  specific  influence  which  is  observed  alter  irradiation 
with  the  Rontgen  rays,  hardly  needs  further  discussion  nowadays. 

It  is,  however,  only  partially  explained  in  what  manner  this 
specific  influence  exerts  itself.  Analogous  to  the  integumental 
changes  produced  by  sunlight,  heat,  caustics,  and  acids,  it  is  largely 
dependent  upon  the  strength  and  the  amount  of  the  Rontgen  rays. 
The  tissues  are  influenced  differently  by  different  rays,  just  as  the 
photographic  plate  is  impressed  differently  by  various  kinds  of 
light.  The  sensitized  coating  of  a  photographic  plate  not  only 
reacts  the  more  intensely  the  stronger  and  longer  it  is  exposed  to 
the  light,  but  it  also  shows  different  impressions,  according  to  the 
different  refrangibility  of  the  rays.  Thus  the  solar  spectrum,  even 
in  long  exposure,  scarcely  affects  that  portion  of  the  plate  where 
red  is  projected,  while  the  blue  and  violet  light  leave  intense 
impressions.  Green  and  yellow  light  produce  stronger  impres- 
sions than  the  red.  The  more  refrangible  the  rays  are,  the  more 
they  are  absorbed  by  the  bromide  of  silver  of  the  photographic 
plate. 

No  doubt  there  is  some  chemical  action  which  causes  metabolic 
disturbances.  It  seems  most  plausible  that  the  Rontgen  rays  in- 
duce fluorescence  in  those  cells  which  possess  fluorescent  proper- 
ties, whereby  chemical  changes  take  place.  The  glue-producing 
tissues,  of  course,  would  be  pre-eminently  concerned,  and  the  rela- 
tionship to  the  gelatine  of  the  bromide  of  silver  is  obvious.  It  is 
a  characteristic  feature  of  the  Rontgen  rays  that  their  effects  do 
not  show  before  a  long  period  of  incubation.  This  stage,  which 
may  be  properly  called  the  latent,  lasts  between  ten  to  twenty 
days.  The  nature  of  this  reaction,  generally  called  Rontgen-light 
dermatitis,  will  be  described  in  the  following  chapter.  The  gen- 
eral symptoms  reported  of  some  patients  as  the  consequences  of 
moderate  irradiation  resemble  those  of  sunstroke,  the  predominat- 
ing sign  being  dizziness. 

The  prolonged  influence  of  the  Rontgen  rays  surely  pro- 
duces a  more  or  less  intense  hypersemia  in  any  part  of  the  human 
body.  In  experiments  of  long  duration,  conducted  by  relia- 
able  investigators,  not  only  hyperemia  and  swelling  of  the  con- 


362  THE    RONTGEN    RAYS 

junctivse,  but  also  retinitis  and  contraction  of  the  pupils  have 
been  observed.  Thus  we  can  readily  understand  that  hyperemia 
takes  place  in  internal  organs,  if  the  powerful  influence  lasts  long 
enough. 

Segny  and  Quenniset  observed  intense  and  irregular  palpita- 
tions of  their  heart  when  irradiating  themselves  for  a  greater 
length  of  time.  Destot  found  that  when  he  irradiated  his  own 
hand  for  an  hour  by  a  static  machine,  the  tubal  wall  being  two 
inches  distant  from  the  skin,  the  pulse  became  fuller  after  ten 
minutes.  But  there  was  no  change  in  the  number.  The  examina- 
tion was  done  by  a  Marcy  sphygmograph. 

If  a  coil  was  used  under  the  same  conditions,  the  pulse  showed 
a  greater  tension  at  first,  which  then  disappeared  gradually; 
finally  arrhythmia  was  observed. 

Attempts  have  been  made  to  approach  this  important  question 
by  experiment  on  the  lower  animals.  Thus  Tarkhanoff  (Gazetta 
degli  Ospedali,  March  4,1897)  observed  that  irradiation  of  the  cere- 
bral hemispheres  of  the  frog  inhibits  reflex  movements.  The  col- 
our of  the  batrachian  integument  appeared  much  darker  when 
the  frogs  returned  to  their  moist  element  after  being  irradiated. 
Riviere's  experiments  on  the  hearts  of  frogs  revealed  no  influence 
upon  their  rhythm  after  long  exposure.  After  prolonged  irradia- 
tion, frogs,  mice,  guinea-pigs,  rabbits,  and  birds,  died,  mostly  with 
paralytic  symptoms. 

How  far  the  eye  is  influenced  by  the  rays  is  not  yet  definitely 
settled.  Among  204  blind  children  De  Courmelles  found  that 
nine  of  them  felt  a  marked  perception  of  the  rays.  The  experi- 
ments of  Galli,  Fuchs,  and  Kreidl  point  to  indifference  of  the 
retina.  But  Wild  reports  a  case  of  panophthalmitis  after  excessive 
irradiation  which  required  enucleation  of  the  eyeball.  The  ante- 
rior media  show  decided  reaction.  Photophobia  is  not  infrequently 
observed  after  irradiation  of  the  face.  After  long  seances  the 
author,  with  very  few  exceptions,  always  noticed  a  burning  sensa- 
tion of  his  eyelids. 

Chalupecky,  after  irradiating  the  eye  of  a  rabbit  for  twenty- 
four  hours,  found  depilation,  conjunctivitis,  and  infiltration  of 
the  cornea,  followed  later  by  the  formation  of  pseudomembranes. 

That  the  Rontgen  rays  exert  a  powerful  influence  upon  the  ac- 
tion of  the  skin,  upon  metabolism,  and  the  temperature  of  the 
blood  has  been  demonstrated  by  Lecercle.     In  one  of  the  author's 


ROXTGEX    THEBAPY  363 

experiments  made  on  dogs,  alopecia  of  the  area,  which  was 
irradiated  for  three  hours,  developed  as  early  as  the  fifth  day. 
The  hair  bulbs  showed  no  atrophy,  but  the  epidermis  and  the 
skin  follicles  were  destroyed.  Microscopical  examinations  of  an 
excised  piece  of  integument  showed  the  usual  signs  of  inflamma- 
tion. 

The  author's  experiments  on  mice  (see  Medical  Record,  June 
18,  1902)  showed  that  depilation  began  on  the  fifth  day  on  an 
averrge,  where  irradiation  was  done  three  hours  a  day.  The  first 
symptoms  showed  at  the  forehead.  During  the  time  of  observa- 
tion the  animals  exhibited  no  disturbing  symptoms — only  one 
among  nine  died  after  being  exposed  to  the  Rontgen  light  for 
twenty-three  hours.  This  mouse  was  irradiated  one-half  hour 
daily  for  one  week,  one  hour  daily  for  one  week,  one  hour  daily 
for  a  second  week,  and  two  hours  daily  for  the  third  week.  Depila- 
tion took  place  over  the  dorsum  then.  Soft  tubes  had  been  used 
for  this  case  exclusively.  The  autopsy  showed  slight  congestion 
of  the  viscera.  Microscopical  examination  revealed  the  general 
signs  of  inflammatory  changes.  In  two  of  the  animals  which  were 
treated  in  the  same  manner,  but  in  which  high-vacuum  tubes  were 
used,  the  integumental  changes  were  slight,  but  the  viscera,  espe- 
cially the  intestines,  were  much  more  hyperaemie.  This  would  also 
be  in  favour  of  the  assumption  that  the  soft  tubes  affect  the  integu- 
ment more  intensely  than  the  viscera,  while  the  hard  ones  affect 
the  skin  to  a  slight  degree  only,  but  by  their  greater  power  of 
penetration  still  exert  their  effects  on  the  viscera.  Intense  iradia- 
tion  showed  marked  reaction  at  the  opposite  side  of  the  body 
(abdomen,  for  instance,  when  the  dorsum  was  exposed).  The 
signs  of  reaction  at  the  opposite  side  appeared  a  week  later,  on  an 
average,  than  those  of  the  area  directly  exposed.  In  men,  visible 
effects  on  the  opposite  side  have  not  been  observed. 

The  microscopical  examination  of  extirpated  tissues,  when 
irradiated  after  excision,  was  always  negative.  An  extirpated  tes- 
ticle of  an  animal,  for  instance,  showed  the  same  structure  after 
prolonged  irradiation  as  the  other,  which  was  not  exposed. 

So  much  for  observed  facts.  The  question  how  these  inflamma- 
tory processes  are  originated  cannot  be  easily  answered,  because  it 
touches  not  only  physics  and  chemistry,  but  also  presents  physiolog- 
ical, pathological,  and  even  bacteriological  factors.  It  seems,  how- 
ever, that  it  can  be  answered  best  on  the  basis  of  clinical  observa- 


364  THE    RONTGEN    RAYS 

tion.  While  experiment  on  the  lower  animals  is  extremely  useful 
for  comparison,  thereby  suggesting  new  ways  for  investigation  on 
the  human  body,  it  cannot  be  conclusive  for  the  pathology  of  man. 
The  thick  hairy  coat  of  the  animal  reacts  to  burns  in  a  way  differ- 
ent from  that  of  the  human  integument.  The  same  must  be  con- 
sidered in  connection  with  the  effects  of  the  Rontgen  rays  upon  the 
skin.  It  will  therefore  be  more  proper  to  compare  our  knowledge 
of  the  conditions  produced  by  ordinary  burns  of  the  human  skin 
with  those  caused  by  the  Rontgen  rays.  In  both  a  disturbance  of 
nutrition  in  the  walls  of  the  blood-vessels  and  its  consequences 
become  at  once  apparent.  By  considering,  for  instance,  the  conse- 
quences of  a  simple  burn  of  the  second  degree,  it  will  be  found 
that  the  destruction  of  the  red  blood-corpuscles,  described  by 
Fraenkel,  Lesser,  Pavlovsky,  Ponfick,  and  Wertheim,  is  of  no  sig- 
nificance even  in  extensive  burns  of  this  kind.  According  to 
Hoppe-Seyler,  even  in  fatal  burns  of  the  second  degree  the  maxi- 
mum of  the  destroyed  blood-corpuscles  did  not  amount  to  more 
than  2.4  per  cent.  The  products  of  tissue  change,  resulting  from 
the  pathological  disintegration  of  the  tissues,  are  much  more  detri- 
mental. They  originate,  according  to  Fraenkel,  in  the  same  man- 
ner as  they  do  in  the  digestion  of  albumin.  The  albumin  is  split, 
absorbs  water,  and  is  finally  transformed  into  albumose  and  pep- 
tones. Krehl  and  Mathews  examined  these  disintegration  products 
of  albumin  within  the  human  bod}-.  From  the  results  of  their 
investigation  we  may  conclude  that  in  burns  of  the  second  degree 
there  is,  besides  destruction  of  the  red  blood-corpuscles,  disintegra- 
tion of  albumin.  The  consequence  of  this  latter  and  most  impor- 
tant change  is  the  formation  of  exudates,  which  produce  albumoses 
during  the  process  of  absorption.  And  albumose,  not  being  a 
product  fit  for  assimilation,  is  eliminated  from  the  organism  by 
the  way  of  the  kidneys. 

The  greater  or  lesser  severity  of  the  clinical  symptoms  seems 
to  be  dependent  upon  the  various  degrees  of  toxicity  of  these 
substances.  In  this  way  the  fatal  outcome  of  extensive  burns  of 
the  second  degree  is  also  explained.  In  addition,  the  large  loss  of 
fluid  (blood  plasma)  must  be  considered,  which  is  also  the  larger 
the  more  widely  the  burned  surface  extends.  The  waste  of  fluid 
causes  a  loss  of  the  natural  resistance  in  the  organism,  so  that 
these  toxic  products  find  a  much  more  favourable  soil. 

In  burns  of  the  second  degree  the  destruction  of  the  red  blood- 


RONTGEN    THERAPY  365 

corpuscles  is  of  much  greater  importance,  since  the  elimination  of 
a  large  quantity  of  them  lias  effects  similar  to  Ihose  of  carbonic- 
acid  poisoning.  To  this  is  added  the  result  of  absorption  of  the 
products  of  the  disintegrated  tissue  (toxaemia). 

The  difference  between  an  ordinary  burn  ami  the  changes  of 
tissue  caused  by  Rontgen  light  consists,  as  lias  been  alluded  to 
above,  in  the  slow  development  of  the  process.  The  peculiar  chem- 
ical influence  of  the  Rontgen  light  on  the  tissues  is  exerted  in  such 
a  manner  that  the  nutrition  of  the  cells  is  impaired.  It  is  only 
when  this  impairment  has  reached  a  greater  degree  that  the  signs 
described  above  manifest  themselves.  And  these  signs  are  again 
influenced  by  the  strength  and  the  amount  of  the  Rontgen  light. 
A  greater  or  lesser  degree  of  predisposition  is  also  of  significance. 
Effluvium  capillorum  is  explained  by  inflammatory  processes  in  the 
matrix  cells. 

That  the  Rontgen  rays  possess  bactericidal  properties  cannot  be 
doubted  any  longer,  although  the  various  reports  on  this  subject 
differ  widely.  The  antibacterial  effect  of  sunlight  is  an  illustra- 
tive analogy.  "  Where  the  sunlight  has  no  access,  the  physician 
will  soon  appear,"  is  an  old  and  significant  Italian  proverb.  In 
harmony  with  this  consideration,  derived  from  the  observation  of 
the  development  of  tuberculosis,  is  the  fact  that  cultures  of  the 
tubercle  bacillus  die  after  exposure  to  sunlight  for  three  hours. 
When  we  consider  the  great  similarity  between  the  effect  of  sunlight 
and  that  of  the  Rontgen  rays,  the  bactericidal  property  of  the  lat- 
ter appears  to  be  evident.  And  in  fact  the  experiments  of  Lortet, 
Genoud,  Fiorentini  and  Luraschi,  Frantzius,  Miihsam,  Rieder  and 
Holzknecht  not  only  showed  that  the  rays  exert  a  direct  bacteriodal 
influence  on  the  cultures,  but  also  arrest  further  development  of 
bacterial  infection.  That  it  is  not  the  electricity,  but  a  specific 
agent  of  its  own  which  is  responsible  for  the  antibacterial  influ- 
ence of  the  rays,  is  evident  from  the  fact  that  the  growth  of  the 
same  cultures  was  not  impaired  if  any  other  electric  means  were 
used. 

Rieder  used  a  Voltohm  tube  and  an  induction-coil  with  a  spark 
length  of  ten  inches,  permitting  of  3,000  interruptions  per  min- 
ute. He  placed  the  cultures  in  Petri  dishes  at  a  distance  of  three 
inches  from  the  target.  They  were  protected  by  a  perforated  sheet 
of  lead.  It  is  evident  that  if  irradiation  took  place  through  the 
hole  made  in  the  centre  and  covered  with  black  paper  which  was 


366  THE    BONTGEN"    RAYS 

not  permeable  by  daylight,  the  pure  effect  of  the  Rontgen  light 
could  be  studied,  while  if  the  opening  was  left  free,  the  influence 
of  daylight  would  have  come  into  consideration.  In  most  cases, 
however,  the  result  was  the  same,  whether  daylight  had  had  access 
or  not. 

Lortet  and  Genoud,  after  inoculating  animals  with  the  bacillus 
of  tuberculosis,  irradiated  some  of  them  daily  for  a  period  of  seven 
weeks.  None  of  the  irradiated  animals  showed  any  signs  of  infec- 
tion, while  the  non-irradiated  ones  developed  abscesses  and  showed 
rapid  emaciation.  Fiorentini  and  Luraschi  found  that  irradiation 
influenced  the  infected  tissues  considerably,  thus  corroborating  the 
observation  of  Lortet  and  Genoud.  Miihsam,  who  inoculated 
guinea-pigs,  found  that  general  tuberculosis  was  not  influenced  by 
the  rays,  but  that  the  local  process  was  either  inhibited  or  dimin- 
ished. 

As  this  most  important  question  stands  at  the  present  time,  it 
seems  that  a  powerful  effect  on  the  bacillus  tuberculosis  is  not 
exerted  by  the  rays,  at  least  not  sufficiently  powerful  as  to  be 
utilized  in  practice.  That  an  influence  exists  can  hardly  be 
doubted,  and  to  the  author  this  seems  to  be  less  of  a  bactericidal 
than  of  an  inflammatory  nature.  It  is  always  well  to  remember 
that  in  tuberculosis  not  only  the  bacillus,  but  also  that  product  of 
metamorphosis,  which  we  know  as  the  tuberculous  nodule,  is  to  be 
considered.  Artificial  hyperemia,  as  has  been  shown  by  Roki- 
tansky,  may  also  arrest  the  development  of  tuberculosis.  If  it  is 
appreciated  that  tuberculosis  is  still  the  most  important  of  all 
diseases,  it  appears  to  be  well  worth  while  to  investigate  this  prov- 
ince still  more  thoroughly. 

Potato-cultures  of  the  Bacillus  prodigiosiis  exposed  by  von 
Wolfenden  and  Ross  in  test-tubes  (Lancet,  1898,  p.  1752)  showed 
stimulation  of  their  growth  after  an  hour's  irradiation.  Their 
inductive  coil  had  a  spark  length  of  18  inches,  their  voltage 
amounted  to  6,  and  the  amperage  to  about  10. 

It  seems  that  the  glass  of  the  test-tubes  offered  an  obstacle 
to  the  permeation  by  the  rays. 

Cultures  of  the  Staphylococcus  pyogenes  aureus  on  gelatin, 
when  exposed  for  an  hour,  showed  diminishing  of  their  growths 
under  the  hole  in  the  centre.  The  same  result  was  obtained  in  cul- 
tures of  the  Bacillus  coli  communis.  The  vibrio  of  cholera  placed 
on  agar  responded  very  readily  after   an   exposure   of   forty-five 


RONTGEN    THERAPY  367 

minutes  only.  Jn  fact,  the  whole  area  corresponding  to  the  open- 
ing in  the  centre  was  practically  free  from  any  colonies. 

The  same  result  was  obtained  in  agar-culture  of  the  Typhoid 
bacillus,  while  blood-serum  cultures  of  the  Klebs-Loeffler  bacillus 
required  longer  irradiation  until  their  further  development  wa- 
arrested. 

From  these  observations  it  may  be  learned  that  especially  the 
staphylococcus,  Bacillus  coli  communis,  vibrio  of  cholera,  and  the 
Typhoid  bacillus  were  destroyed  if  grown  in  gelatin,  agar,  or 
blood-serum.  It  would  be  a  consummation  devoutly  to  he  wished 
if  these  bacteria  could  also  he  reached  by  the  rays  when  develop- 
ing inside  of  the  living  body.  But  our  present  means  do  not  per- 
mit an  effect  so  powerful  that  the  developing  process  of  bacteria 
in  vivo  would  be  inhibited. 

It  seems  that  the  various  reactions  shown  by  the  various  bac- 
terial types  are  in  proportion  to  the  different  qualities  of  their 
plasma. 

The  great  technical  difficulties  connected  with  the  study  of  the 
details  of  intercellular  life  naturally  suggested  approaching  some 
of  these  problems  by  experiments  on  the  lower  animals,  like  the 
protozoa,  which  permit  of  a  closer  study  of  their  protoplasma, 
Schaudinn  (Pflueger's  Archiv  fiir  die  gesammte  Physiologie,  Band 
lxxvii),  for  instance,  found  that  among  the  protozoa,  Labyrinthula 
dacryocystis  Cienth,  showed  no  changes  at  all.  The  plasma  of 
these  types  is  viscid  and  inert.  It  is  indifferent  to  all  kinds  of 
irritation,  while  the  lively  Amoeba  princeps  (Ehrbg.),  the  liquid 
plasma  of  which  contains  large  quantities  of  water,  shows  consid- 
erable change,  and  dies  after  being  irradiated  for  ten  hours.  All 
kinds  of  infusoria  perish  after  being  irradiated  for  six  hours. 

Maldiney  and  Thouvenin  found  that  the  seeds  of  the  morning- 
glory  {Convolvulus  arvensis)  and  of  the  watercress  (Lepidium 
sativum)  showed  the  signs  of  sprouting  much  more  rapidly  when 
they  were  irradiated  for  an  hour. 

All  their  experiments  point  to  the  fact  that  the  rays,  if  used 
moderately,  have  an  exciting  and  invigorating  effect  upon  the  or- 
ganism, while  when  used  excessively  are  apt  to  exert  a  destructive 
or  paralyzing  influence.  This  is  in  entire  accord  with  clinical 
observation. 


36S 


THE    KONTGEX    EAYS 


ROXTGEX-EAY    DERMATITIS 

The  pathological  changes  of  the  skin,  called  Eontgen-ray  der- 
matitis and  generally  known  as  X-ray  burns,  resemble  those  in 
ordinary  burns.  Just  as  in  ordinary  burns,  these  different  degrees 
should  be  distinguished. 

The  first  degree  is  characterized  by  the  symptoms  of  hyper- 
emia. Epidermis  and  cutis  are  infiltrated  and  the  temperature  is 
somewhat  higher.  Exfoliation  takes  place  in  small  scales.  The 
most  pronounced  subjective  symptom  is  a  tormenting  itching  in 

the  skin.  Effluvium  capil- 
lorum,  which  manifests  it- 
self, as  a  rule,  without  pro- 
ducing any  visible  signs  in 
the  integument,  belongs  in 
the  same  category.  It  seems 
that  there  is  a  regressive 
metamorphosis  (atrophy)  of 
the  differential  elements — 
viz.,  the  glands,  hairs,  and 
nails.  Most  cases  of  Eont- 
gen-ray dermatitis  belong  to 
this  category. 

The   first   symptom   used 
to  be  the  turgescence  of  the 
skin,  which  may  appear  as  early  as  three  days  after  the  exposure. 
In  the  majority  of  cases  the  unmistakable  signs  do  not  show  be- 
fore the  tenth  day. 

The  main  feature  of  the  second  degree  consists  in  the  forma- 
tion of  blisters,  the  clear  or  yellowish  contents  of  which  lift  the 
corneal  from  the  mucous  stratum  of  the  rete  Malpighi  (Fig.  262). 
The  inflammatory  signs  are  well  pronounced,  the  tension  is  con- 
siderable, and  the  pain  is  intense.  After  the  removal  of  the  blis- 
ters, the  corium  is  exposed  as  a  red  and  sore  surface  (bullous 
form  of  Eontgen-ray  dermatitis).  The  excoriated  surface  shows 
a  yellowish-red  appearance.  Some  cases  look  like  having  been  var- 
nished. In  the  further  course  some  portions  show  a  fibrinous 
cover  like  croup-membranes,  which  adhere  tightly.  The  abundant 
secretion  from  the  coarse  granulations  is  of  a  sero-purulent  char- 
acter. 


Fig.  262. — Rontgen  Light  Buhn  of  the 
Second  Degree. 


I.'OXTCKX    THERAPY  369 

The  third  and  graves!  degree  is  characterized  by  the  escharotic 

destruction  of  the  irradiated  tissues.  They  show  the  signs  of  dry 
gangrene,  and  their  appearance  is  brownish  Mack.  There  arc  in- 
tense inflammatory  signs  and  the  temperature  rises  accordingly. 
The  patient  suffers  considerably.  If  the  necrotic  area  exfoliates 
by  a  slow  suppurating  process,  or  if  it,  as  it  should  properly  be, 
is  removed  by  the  surgeon,  a  granulating  ulcer  remains,  the  cica- 
trization of  which  may  take  months  (necrotic  form  of  RiJntgen- 
ray  dermatitis)    (Fig.  293). 

Then  the  integument  becomes  hyperaemic,  erythema  of  a  light 
red  appearance  develops  and  changes  Like  pigmentation  set  in. 
If  the  irradiation  is  discontinued  in  this  stage,  these  signs,  espe- 
cially erythema  and  pigmentation,  disappear  in  two  or  three  days. 
The  integumental  turgescence  lasts  somewhat  longer.  After  depila- 
tion  the  first  signs  of  the  recurrence  of  the  hair  show  in  five  to  nine 
weeks.  After  a  few  weeks  there  is  complete  recovery,  though 
sometimes  slight  pigmentation  of  the  integument  remains. 

If  the  irradiation  is  continued  the  skin  may  become  burned 
and  scaly;  or  the  bullous  type  of  the  Rontgen-light  dermatitis  sets 
in.  In  this  form  intense  reaction  takes  place  after  an  incubation 
of  about  two  weeks.  This  is  of  a  subjective  as  well  as  of  an 
objective  character,  and  lasts  about  as  long  as  the  period  of  incuba- 
tion did.  Then  cicatrization  follows.  If  the  area  of  irradia- 
tion was  covered  with  hairs,  depilation  takes  place.  The  process 
of  regeneration  of  hair  is  slow,  and  pigmentation  and  teleangiec- 
tasis nearly  always  remain. 

The  necrotic  state  of  the  Rontgen-ray  dermatitis  develops  a  few 
days  later  than  the  bullous  form  as  a  rule,  and  requires  months 
for  its  cure.  This  type  reminds  one  of  the  stationary  form  of 
gangrene,  which  is  known  as  "  glacier-gangrene  "  in  Europe.  The 
antediluvian  face  of  the  old  inspector  of  the  ice-grotto  at  the 
Eiger  glacier  in  Switzerland,  well  known  to  many  medical  tourists, 
affords  a  real  study  of  this  interesting  tissue  change. 

There  is  a  type  of  chronic  Rontgen-light  dermatitis  which  is 
especially  found  among  physicians  who  devote  a  great  deal  of 
time  to  irradiation.  Fig.  263  shows  the  wrinkled,  shrivelled, 
vulnerable,  and  partially  cracked  terra-cotta  hand  of  a  physician, 
who  had  done  daily  skiagraphic  work  since  the  early  Rontgen  era, 
It  represents  the  dorsal  surface,  which  he  turns  against  the  Ront- 
gen tube  in  order  to  ascertain,  bv  the  study  of  the  bones  of  his  own 
25 


370 


THE    EOXTGEN    RAYS 


hand,  what  degree  of  translucency  exists.  The  tip  of  the  fourth 
finger  was  the  most  exposed  target,  which  finds  its  conspicuous 
expression  in  the  black  colourization  of  the  nail  and  the  onychia. 
Next  to  it  the  little  finger  suffered  most,  which  is  illustrated  by 
the  deep  black  of  its  nail.  The  nail  of  the  middle  finger  is  less 
blackened,  and  the  index  still  less,  while  that  of  the  thumb,  which 

is  held  sidewardly,  is  fairly 
normal. 

The  hands  of  Rontgo- 
active  physicians  show 
the  integument  wrinkled 
and  shrivelled;  the  nails 
horny  and  cracked,  and  the 
phalanges  thickened,  so 
that  there  is  tension  dur- 
ing movement.  The  elas- 
ticity is  lessened  and  the 
sensibility  increased.  Ef- 
fluvium capillorum  is  an 
invariable  accompaniment. 
In  some  cases  the  forma- 
tion of  warts  and  rhagades 
is  observed.  Undoubtedly 
there  is  a  cumulative  in- 
fluence. 

Experience  has  taught 
us  that  in  all  cases  of 
Rontgen-light  dermatitis, 
other  circumstances  being  equal,  long  exposures  had  taken  place; 
and  it  is  therefore  obvious  that  short  exposures  are  the  best  safe- 
guard against  injury.  But  then  the  question  is :  Shall  we  reach 
the  desired  result,  whether  for  diagnosis  or  therapy,  by  a  short 
exposure?     If  not,  what  kind  of  prophylaxis  must  be  used? 

In  order  to  appreciate  this  important  point  thoroughly  we 
must  also  consider  some  contributing  factors — viz.,  the  construc- 
tion of  the  tube,  the  penetration  power  of  its  light,  the  distance 
from  the  irradiated  body,  the  position  of  the  object,  the  number 
of  interruptions,  and  the  size  of  the  secondary. 

Whether  an  accumulator,  a  static  machine,  or  a  coil  be  used 
seems  to  be  irrelevant.    But,  as  mentioned  in  the  author's  previous 


Fig.  263. — Rontgen-hand. 


RONTGEN    THERAPY  371 

publications  on  this  subject,  we  have  to  reckon  with  Rontgen  light 
susceptibility,  existing  in  some  individuals,  jus!  as  much  as  we 
have  to  do  with  iodoform  idiosyncrasy.  The  author's  statistics  a1 
the  German  Poliklinik  of  Xcw  York,  which  are  based  upon  twenty 
years  of  continuous  observation,  show  that  about  every  fiftieth 
individual  becomes  affected  with  dermatitis  when  treated  with  iodo- 
form. Since  such  idiosyncrasy  cannot  be  diagnosticated  before  the 
dermatitis  makes  its  appearance,  we  shall  never  be  able  to  prevent 
it.  But  what  we  can  do  is  to  recognise  it  in  its  early  stage,  and 
if  this  is  done,  further  spreading  can  be  arrested  by  simply  dis- 
carding its  further  use. 

There  are,  however,  two  points  of  difference  between  the  iodo- 
form and  the  Rontgen-light  susceptibility.  In  the  first  place,  a 
non-susceptible  patient  will  not  show  any  signs  of  iodoform  derma- 
titis, no  matter  how  long  he  may  iodoformize  himself,  while  there 
is  no  individual  who  would  not  be  burned  by  the  Rontgen  light 
if  its  influence  is  kept  up  long  enough.  And,  secondly,  the  Ront- 
gen dermatitis  will  not  stop  as  soon  as  further  irradiation  is  dis- 
continued. The  peculiar  features  of  the  Rontgen  rays  not  to  show 
the  injurious  effects  as  a  rule  before  the  tenth,  sometimes  not 
before  the  twentieth  day  after  the  first  exposure,  stands  in  the  way 
of  an  early  and  rational  prophylactic  therapy.  The  only  method 
by  which  we  may  so  far  determine  whether  a  susceptibility  exists 
or  not  is  by  tentative  exposures.  So  it  may  sometimes  be  a  chain 
of  little  causes,  long  exposures,  short  distances,  powerful  apparatus, 
condition  of  patient,  and  weather,  which  in  their  entirety  may  be 
the  stimulus  for  the  reaction.  Besides  this  susceptibility,  which  is 
born  with  the  individual,  and  is  to  be  regarded  as  an  imponderabili- 
um,  temporary  susceptibility  exists,  which  may  be  attributed  to 
temporary  bodily  conditions,  to  pathological  changes,  or  to  climatic 
influences.  The  author  has  repeatedly  called  attention  to  his  ob- 
servation that  when  suffering  from  a  slight  Rontgen-light  derma- 
titis himself  he  could  note  a  marked  increase  of  the  symptoms 
during  sultry  weather.  The  patients  treated  on  such  days  had  a 
similar  experience. 

He  does  not,  however,  believe  that  the  question  of  susceptibility 
requires  much  consideration,  as  far  as  exposures  for  diagnostic 
purposes  are  concerned,  since,  with  our  present  methods,  the  length 
of  time  needed  is  very  much  shorter.  Even  if  repeated  exposures 
have  to  be  taken  the  author  has,  so  far,  not  seen  a  Rontgen-light 


372  THE    EOXTGEN"    BAYS 

dermatitis  before  the  fifth  repetition,  the  intervals  having  been 
from  two  to  three  days.  And  these  cases  were  slight,  the  first  or 
second  degree.  Still,  as  already  said,  with  our  present  apparatus, 
a  certain  length  of  exposure  invariably  causes  burning,  whether 
the  individual  be  susceptible  or  not.  If  long  exposures  are  re- 
sponsible in  nearly  all  cases  of  Rontgen-light  dermatitis,  we  shall 
naturally  try  to  shorten  them,  as  emphasized  above.  This  we  can 
do  only  to  a  certain  extent,  if  we  are  seeking  full  and  distinct 
diagnostic  information.  Unfortunately,  the  best  skiagraphs  are 
obtained  by  long  exposures,  made  with  tubes  of  low  vacuum.  This, 
in  addition,  requires  the  use  of  a  strong  current.  So,  in  order  to 
get  out  the  structural  details,  three  irritating  factors  unite  their 
influence,  the  long  exposure,  the  soft  tube,  and  the  intense  current. 
A  tube  with  a  high  vacuum  requires  only  a  short  exposure,  but  the 
details  of  the  skiagraph  are  by  no  means  brought  out  as  well.  So, 
theoretically,  if  the  question  of  dermatitis  did  not  exist,  we  would, 
as  a  rule,  combine  very  low  vacua,  very  long  exposures,  and  cur- 
rents  of  high  intensity. 

Fortunately,  the  longest  exposure  (the  pelvis)  does  not  now, 
with  the  aid  of  the  Wehnelt  interrupter,  require  more  than  four 
to  five  minutes'  exposure,  and  this  will  be  tolerated  even  by  a  sus- 
ceptible individual.  So,  practically,  we  do  not  need  to  fear  much 
in  our  diagnostic  efforts,  and  if  we  could  make  the  rays  still 
more  powerful,  in  order  to  get  more  differentiation,  we  would  not 
hesitate  to  do  it. 

But  when  repeated  exposures  of  ten  minutes  time  are  neces- 
sary, the  question  of  susceptibility,  as  well  as  of  ordinary  cumula- 
tive irritation,  should  be  considered,  and  therefore  the  intervals 
between  the  exposures  should  be  made  long — a  week  on  an  average. 

None  of  the  severe  disturbances,  however,  reported  in  literature 
were  due  to  short  exposures,  most  of  them  being  observed  in 
professional  electricians.  A  tube-maker  in  a  Hamburg  laboratory, 
for  instance,  by  testing  the  tubes  with  his  own  hands,  sustained  a 
burn  of  the  third  degree,  the  treatment  of  which  was  apparently 
neglected.  Over  the  basis  of  the  deep  ulceration  an  epithelioma 
formed  and  metastasis  in  the  glands  developed,  so  that  disarticu- 
lation in  the  shoulder-joint  had  to  be  undertaken. 

Lloyd  (Medical  Record,  April  A,  1903,  p.  554)  reported  the 
case  of  a  tube-maker  in  Edison's  laboratory  who  had  received 
very  severe  burns  on  his  hands  and  head.     Finally  he  lost  all  the 


RONTGEN    THEKAPY  373 

skin  of  his  hands.     lie  was  skin-grafted  in  two  or  three  hospitals, 

and  finally  returned  to  New  York  with  an  epithelioma  developed 
on  the  Rontgen-ray  burn  of  the  right  hand.  This  epithelioma 
grew  rapidly  while  he  was  under  Rontgen-ray  treatment,  and 
finally  amputation  had  to  be  performed.  By  the  courtesy  of  Mr. 
Thomas  A.  Edison  the  author  learned  that  the  other  arm  of  his  un- 
fortunate assistant  began  to  show  such  aggravated  pathological 
changes  that  its  amputation  has  also  become  necessary. 

Tattle  (ibidem)  referred  to  a  man  whose  thigh  he  had  to 
amputate  because  of  the  result  of  an  X-ray  burn.  A  careful  patho- 
logical and  microscopical  study  of  the  X-ray  burn  as  well  as  of 
the  parts  around  it  had  been  made  by  William  Vlssman,  whose 
conclusion  was  that  it  was  the  result  of  the  production  of  an 
endarteritis  and  a  periarteritis. 

As  far  as  the  author  could  ascertain,  extremely  long  exposures 
had  preceded  the  injury.  The  pathological  changes  in  the  tissues 
were  studied  by  IJnna,  Gilchrist.  Kienboeck,  Darier,  Jutassy, 
Kibbe,  Gassmann,  Scholz,  Oudin,  and  the  author.  Unna  found  a 
slight  increase  of  the  nuclei  in  the  papillary  body  as  well  as  around 
the  blood-vessels.  At  the  same  time  there  was  more  pigment  in 
the  upper  layer  of  the  cutis. 

Kibbe  found  dilatation  of  the  blood-vessels  and  rich  cellular 
proliferation. 

Gilchrist  noticed  abundant  brown  pigment  in  the  mucous 
stratum,  and  dilated  vessels  in  the  corium,  while  the  corneal  struc- 
ture was  thickened. 

Darier  observed  enlargement  of  the  reticular  cells,  thickening 
of  the  epidermis  and  atrophy  of  the  hair  and  its  follicles,  and  of 
the  glands. 

Examination  of  burned  tissue  made  by  the  author  (see  The 
Pathology  of  the  Tissue  Change  caused  by  the  Rontgen  Rays,  etc. 
Transactions  of  the  Medical  Society  of  the  State  of  New  York, 
January  28,  1902)  showed  a  large  amount  of  dense  connective 
tissue  and  marked  vascularity.  The  epithelial  cells  of  the  skin 
were  diminished  in  size.  The  tunica  intima  of  the  small  blood- 
vessels was  thickened,  their  calibre  thus  becoming  narrower.  The 
muscularis  and  adventitia  appeared  to  be  affected  in  the  same 
manner.  The  muscularis  may  thus  become  atrophic.  All  this 
points  to  a  process  of  constriction  of  the  vessels.  Some  of  the 
areas  show  still  greater  degeneration,  the  tunicas  of  the  small  ves- 


374 


THE    RONTGEN    RAYS 


sels  being  converted  into  a  colloid  mass  and  the  intima  being 
entirely  severed  from  the  muscularis. 

In  the  case  of  Turtle,  described  above,  endarteritis  was  ob- 
served, which  had  extended  nearly  four  inches  underneath  the 
burned  area. 

The  hair  extracted  after  prolonged  irradiation  is  found  to  have 
lost  its  structure.     It  ends  in  a  point  instead  of  showing  a  root. 

Zehmann  found  that  the 
bulb  at  the  end  of  the  root 
often  showed  slight  swelling. 
The  course  of  the  Ront- 
gen-light  dermatitis  is  de- 
pendent, of  course,  upon  the 
intensity  and  extent  of  the 
irradiation,  and  upon  the 
kind  of  affected  tissues.  The 
prognosis  of  the  second  and 
first  degree  is  extremely 
favourable.  The  integu- 
mental  area  situated  di- 
rectly above  the  bone,  as 
on  the  skull,  chin,  thorax, 
spinal  column,  tibia,  etc., 
is  especially  unfavourably 
located.  The  necrotic  form 
naturally  represents  the  se- 
verest type. 

The  more  intensely  the 
dermatitis  sets  in,  the  more 
the  tissues  are  affected  and 
the  more  marked  the  sequelas 
appear.  The  following  cases  observed  by  the  author  may  serve  as 
illustrations.  The  bullous  form  of  Rontgen-ray  dermatitis  was 
observed  in  a  man  of  thirty-eight  years,  who  in  the  course  of  two 
years  had  to  submit  to  five  thoracotomies  for  pyothorax.  In  view 
of  the  thickened  pleura,  which  lined  the  immense  thoracic  cavity, 
the  author  had  resorted  to  pleurectomy,  and  a  few  weeks  later  the 
Rontgen  rays  were  expected  to  give  information  as  to  the  extent  of 
the  cavity  as  well  as  of  the  previous  rib-resection. 

At  first  soft  tubes  were  employed,  the  use  of  which  gave  but 


Fig.    264. — Telangiectasis    two    tears 
after  Rontgen  Light  Dermatitis. 


RONTGEN    THERAPY  375 

little  contrast.  This  phenomenon  was  erroneously  explained  by  the 
reason  that,  in  spite  of  the  removal  of  a  large  pleural  portion,  still 
a  considerable  part  of  thickened  pleura  had  remained,  which 
might  have  veiled  the  image  of  the  ribs.  When  resecting  the  ribs 
shortly  after  the  last  exposure  the  author  found  them  to  be  of 
very  soft  consistency,  which  showed  the  absorption  of  calcareous 
matter  on  account  of  the  long  duration  of  the  inflammatory  proc- 
ess (inflammatory  atrophy).  After  having  repeated  his  unsatis- 
factory efforts  seven  times,  harder  tubes  were  resorted  to  in  com- 
bination with  a  high  current  and  longer  exposure,  which  caused 
a  bullous  dermatitis.  The  incubation  lasted  ten  days,  the  skin 
was  light-red  first  and  then  dark-red.  Later  on  a  blister  the  size 
of  a  large  hand  formed,  the  contents  of  which  consisted  of  serum. 
After  the  blister  was  removed  an  excoriated  surface  was  exposed, 
which  cicatrized  under  a  xeroform  dressing  in  three  weeks.  Fig. 
264  illustrates  the  pigmented  integument  and  indicates  the  pres- 
ence of  a  telangiectatic  area  two  years  after  healing  of  the  derma- 
titis.   The  patient  was  of  blond  complexion. 

The  same  accident  happened  in  a  blond  man  of  twenty-five 
years,  who  had  suffered  from  traumatic  lung  abscess  for  three 
years.  In  trying  to  measure  the  various  distances  of  the  walls 
of  the  cavity  five  exposures  were  made.  A  soft  tube  was  used. 
Thirteen  days  after  the  last  exposure  a  blister  of  the  size  of  the 
palm  of  the  hand  appeared  on  the  anterior  thoracic  wall,  opposite 
the  opening  of  the  cavity.  The  contents  of  the  blister  consisted 
of  serum  of  light  yellowish  colour.  After  the  opening  and  re- 
moval of  the  blistered  tissue  a  superficial  non-suppurating  excoria- 
tion remained,  which  cicatrized  under  the  application  of  a  10-per- 
cent xeroform  lanolin  ointment.  Fig.  262  shows  the  excoriated 
surface  three  days  after  the  first  symptoms  of  dermatitis  had 
appeared. 

In  both  cases  individuals  were  concerned  the  vitality  of  whose 
tissues  had  been  lowered  by  exhaustive  processes  which  had  lasted 
for  several  years.  In  both  instances  suppurating  cavities  were 
irradiated  which  seemed  to  be  apt  to  impart  a  resistance  of  the 
superimposed  structures.  A  current  of  high  intensity  was  em- 
ployed, and  the  exposure  was  from  five  to  six  minutes  each  time. 
In  a  third  case  the  long-continued  influence  of  a  plaster-of- 
Paris  dressing  in  connection  with  axillary  folliculitis  was  sufficient 
reason  for  the  lowering  of  the  vitality  of  the  integument.     If  the 


376  THE    EONTGEN    RAYS 

integument  is  in  a  stage  of  irritation  on  account  of  the  presence 
of  sykosis,  favus,  or  similar  skin  affections  the  predisposition  is 
naturally  more  marked. 

The  treatment  of  the  inflammation  caused  by  the  Eontgen  light 
is  virtually  the  same  as  that  of  ordinary  burns.  In  simple  derma- 
tosis (burn  of  the  first  degree)  Avarm  applications  of  Burow's  solu- 
tion are  most  comfortable  for  the  patient.  For  the  bullous  form 
(second  degree)  a  10-per-cent  xeroform-gauze  dressing,  after  the 
blisters  are  opened  and  removed,  is  indicated  for  the  first  few  days. 
Later  on  a  dressing  of  a  10-per-cent  xeroform-lanolin  ointment 
is  recommended,  which  is  changed  daily,  provided  there  is  but 
scant  secretion.  The  necrotic  form  (third  degree)  requires  speedy 
removal  of  the  mortified  tissues,  the  after-treatment  is  conducted 
on  the  ordinary  principles  of  wound  treatment,  xeroform  or  iodo- 
form gauze  being  used,  the  latter  being  preferred  if  there  is  much 
secretion.  Torpid  granulations  are  stimulated  by  an  8-per-cent 
solution  of  chloride  of  zinc.  Skin-grafting  is  often  indicated  in 
obstinate  cases.  In  the  chronic  form  moisture  must  be  avoided. 
Temporary  bathing  in  a  normal  salt-solution,  however,  is  recom- 
mended. 

The  Method  of  Therapeutic  Irradiation. — The  effect  of  irradia- 
tion depends  mainly  upon  the  intensity  of  the  Eontgen  rays  and  the 
vacuum  of  the  tube,  the  size  of  the  induction  coil,  the  strength  of 
the  primary  current,  the  number  of  interruptions,  the  frequency 
and  duration  of  the  seances,  the  distance  of  the  tube,  and  last  but 
not  least,  the  individuality  of  the  irradiated  tissue  are  also  factors 
well  to  be  considered.  As  a  rule,  an  induction  coil  which  gives  a 
spark-length  of  ten  inches  answers  the  purpose  well,  an  amperage 
of  three  being  sufficient  on  an  average.  A  dosage  of  five  to  six 
amperes  should  be  resorted  to  early  in  the  treatment  of  malignant 
growths.  As  alluded  to  in  the  foregoing  section,  soft  tubes  exert  a 
stronger  influence  upon  the  skin  than  the  hard  ones.  Irradiation 
with  a  hard  tube  may,  however,  be  followed  by  intense  integu- 
mental  reaction,  if  it  is  used  in  connection  with  a  very  powerful 
induction  coil.  The  number  of  interruptions  also  represents  a  con- 
tributing factor.  It  is  assumed  that  the  intensity  is  the  greater 
the  more  frequent  the  interruptions  are.  Tubes  provided  with  an 
attachment  for  regulating  the  vacuum  are  best  fitted  for  thera- 
peutic purposes.  The  author  employs  the  same  kind  of  tubes 
which  he  found  most  useful  for  diagnosis.     For  static  machines 


RONTGEN    THERAPY  377 

the  same  principles  hold  good.  Various  efforts  to  ascertain  and 
regulate  the  degree  of  penetration  have  been  made.  The  radio- 
chromometer  of  Benoist  and  the  ampoule  a  osmo-regulateur  of 
Villard  represent  some  of  the  efforts  to. solve  this  question. 

The  principle  of  the  apparatus  of  Holzkneeht,  called  chromo- 
radiometer,  is  based  upon  the  property  of  various  salts  to  be  more 
or  less  eolourized  by  the  influence  of  the  rays.  Such  salts  alter 
being  deeply  eolourized  by  the  rays  are  made  up  in  a  scale  which 
also  contains  the  same  salts,  not  yet  influenced  by  the  rays.  If  the 
fresh  salt,  placed  at  the  object  to  be  irradiated,  shows  the  same  de- 
gree of  colourization  which  its  eolourized  companion  has,  sufficient 
influence  is  exerted,  and  further  irradiation  would  better  be 
stopped.  Ingenious  as  the  apparatus  is,  which  is  especially  rec- 
ommended in  the  treatment  of  lupus,  it  has,  in  its  present  stage, 
only  a  very  limited  field  of  usefulness.  For  the  experienced  oper- 
ator the  colourization  of  the  tubal  light  indicates  the  degree  of  the 
vacuum,  yellow  saturated  colour  pointing  to  a  soft  state,  and  a 
green  aqueous  light  being  characteristic  for  the  hard.  If  the  oper- 
ator uses  the  osteoscope  (see  Fig.  12)  he  will  find  the  bones  black 
if  a  soft  tube,  and  gray  if  a  hard  one  is  selected. 

As  to  the  question  of  idiosyncrasy,  reference  is  made  to  the 
foregoing  chapter.  From  a  strictly  practical  standpoint  the  possi- 
bility of  susceptibility  deserves  attention  only  as  far  as  cosmetic 
considerations  are  concerned.  In  other  words,  we  should  make 
clear  to  ourselves  first  what  the  object  of  our  therapeutic  measures 
is.  Little  stress  is  laid  upon  this  point  in  the  many  valuable  pub- 
lications on  this  important  subject.  It  is  not  customary  to  shoot 
at  sparrows  with  cannon-balls.  Why,  if  we  treat  a  hairy  surface 
on  the  face  of  a  fair  lady,  for  instance,  resort  to  means  as  powerful 
as  those  we  employ  in  carcinoma?  And,  on  the  other  hand,  if 
dermatitis  occurs  in  the  face  of  a  fair  lady,  who  simply  wanted 
to  be  treated  for  hypertrichosis,  the  cure  proves  to  be  worse  than 
the  disease.  In  other  words,  when  treatment  for  non-malignant 
diseases  is  intended,  careful  tentative  exposures  should  precede  it. 
If,  then,  erythema  should  appear  after  one  short  exposure,  thus 
proving  the  presence  of  susceptibility,  further  treatment  must  be 
taken  up  only  under  extraordinary  circumstances,  and  after  the 
patient  has  been  fully  informed  of  the  risks.  For  such  purposes 
a  first  exposure  of  five  minutes  is  advised.  A  soft  tube  should  be 
selected.     After  a  week  the  same  procedure,  now  lasting  ten  min- 


378  THE    HONTGEN    RAYS 

utes,  is  to  be  repeated.  If,  after  a  third  exposure,  and  two  weeks 
after  the  first  one,  no  reaction  has  shown  up,  the  patient  is  appar- 
ently not  susceptible.  Then  he  may  on  an  average  be  irradiated 
every  second  or  third  day,  and  at  last  daily,  until  reaction  mani- 
fests itself.    Each  exposure  may  last  from  ten  to  fifteen  minutes. 

During  the  tentative  exposures  the  distance  of  the  tubal  wall 
from  the  skin  should  be  four  inches,  later  on  it  may  be  reduced  to 
one  inch.  The  vicinity  of  the  irradiated  area  must  be  protected. 
This  is  done  by  a  thick  shield  of  lead,  which,  if  moulded  properly, 
attaches  itself  to  the  area  selected;  if  not,  it  must  be  fastened  to 
it  by  a  bandage.  If  the  face  is  concerned,  a  sheet  of  lead,  into 
which  a  hole  is  cut  to  correspond  with  the  area  to  be  irradiated, 
may  be  bent  over  it.  During  the  intervals  xeroform  salve  (1  to  10 
lanolin)  should  be  employed. 

In  treating  malignant  diseases,  we  should  be  governed  by  en- 
tirely different  principles.  That  it  is  absurd  to  protect  the  areas 
which  demand  the  influence  of  a  sort  of  destroying  agent  will 
be  explained  in  the  chapter  on  the  treatment  of  malignant  growths. 
The  fact  that  the  cases  of  Rontgen-ray  dermatitis  reported  were 
invariably  observed  after  long  exposures,  shows  that  the  length  of 
exposures  is  the  most  prominent  causative  factor. 

The  question  how  many  minutes  we  should  expose  our  patient 
at  each  seance,  and  how  many  times  and  in  what  intervals,  in 
order  to  obtain  the  desired  result,  is  not  easily  answered.  After 
irradiating  a  patient  for  a  whole  hour  the  reaction  will  be  a  great 
deal  more  intense  than  if  the  same  dosage  is  given  during  a  ten 
minutes'  seance  on  six  successive  days.  On  an  average  the  natural 
limit  of  each  exposure  should  be  fifteen  minutes.  It  is  much  more 
troublesome  to  reach  the  desired  result  after  exposing  ten  times 
for  ten  minutes  than  once  for  an  hour,  but  it  is  a  great  deal 
safer. 

As  to  the  distance  of  the  tube,  it  appears  to  be  natural  that 
the  nearer  the  tube,  the  greater  the  intensity  of  the  light  is,  a  factor 
which  must  be  considered  in  connection  with  the  lengths  of  expo- 
sures as  well  as  with  the  intensity  of  the  current  and  the  height 
of  the  vacuum.  For  comparison,  it  is  well  to  remember  that  the 
bromide  of  silver  of  the  photographic  plate  shows  an  intense  reac- 
tion at  a  certain  distance,  while  after  increasing  it  to  its  double 
extent  but  one-fourth  of  that  effect  is  shown.  In  most  cases  the 
distance  of  the  tubal  wall  from  the  skin  should  be  four  inches. 


RONTGEN    THEKAPY  379 

As  to  the   modification   of  this  rule,   see   chapter   on   Malignant 

Growths. 

A  most  important  factor  is  the  character  of  the  tissues  irradi- 
ated. Different  tissues  react  differently,  as  emphasized  in  the  fore- 
going chapter.  Different  regions  of  the  body  show  marked  predi- 
lections, the  hairy  part  of  the  skull,  for  instance,  and  those  in- 
tegumental  portions  which  are  immediately  situated  above  a  bone, 
being  especially  inclined.  The  face,  the  dorsum  of  the  hand,  and 
the  mucous  membranes  are  also  more  sensitive.  Children  and 
weak  individuals  seem  to  react  quicker  and  more  intensely,  espe- 
cially after  exhaustive  processes  have  lowered  the  vitality  of  the 
irradiated  tissues,  as,  for  instance,  in  the  case  of  abscess  forma- 
tion, described  in  the  foregoing  chapter. 

The  same  tissues,  when  undergoing  tuberculosis,  carcinoma- 
tous, or  sarcomatous  degeneration  naturally  react  differently 
than  they  do  in  their  normal  state.  Whether  the  colour  of  the 
hair,  complexion,  etc.,  furnish  a  predisposition,  is  still  sub  judice. 
Blond  individuals  seem  to  show  a  special  susceptibility.  All  the 
author's  cases  were  of  light  complexion.  As  described  in  the 
foregoing  chapter,  the  first  signs  of  reaction  are  of  a  subjective  as 
well  as  of  an  objective  nature.  The  subjective  symptoms  are  those 
of  burning  and  itching,  especially  at  night.  The  feeling  of  ex- 
treme tension  is  also  complained  of  by  the  patient  as  a  most 
distressing  sensation.  In  the  beginning,  however,  these  symptoms 
may  be  so  slight  that  the  patient  may  ignore  them.  It  is  neces- 
sary therefore  to  distinctly  call  his  attention  to  this  possible  even- 
tuality. 

The  objective  symptoms  are  integumental  tumescence  and 
change  of  pigmentation,  effluvium  capillorum  and  erythema.  The 
tumescence  is  of  a  diffuse  character,  and  if  it  makes  its  appearance 
in  the  face,  the  patients,  especially  ladies,  enjoy  it,  on  account  of 
its  favourable  influence  on  the  irregularities  of  the  skin  surface, 
and  because  it  clears  the  complexion  somewhat. 

According  to  Scholz  and  Behrend,  histological  investigation 
shows  these  symptoms  to  be  produced  by  the  infiltration  of  the 
integumental  tissue  by  serous  exudations  which  permeate  the 
lymph-spaces  situated  between  the  elements  of  the  stratum  spino- 
sum  first,  and  dilates  them.  Sometimes  the  skin  shows  a  light 
yellowish  or  brownish  colour  of  a  diffuse  nature,  which,  as  a  rule, 
disappears  shortly  after  irradiation  is  stopped.     Sometimes  early 


380  THE    RONTGEN    RAYS 

decolourization  of  the  hair  is  observed,  especially  of  brown  individ- 
uals. In  the  majority  of  cases,  pigmentation  as  well  as  decolour- 
ization appears  as  a  late  symptom  of  superirradiation. 

Pigmentation  is  due  to  the  hyperaemic  condition  caused  by  the 
influence  of  the  rays  on  the  capillaries,  diapedesis  of  blood-cor- 
puscles through  their  walls  is  rendered  possible  then  in  a  moder- 
ate extent.  Extravasation  of  blood-plasma  containing  haemoglobin 
in  the  dissolved  state,  takes  place  at  the  same  time.  To  this  proc- 
ess the  yellow  tint  of  the  hyperaemic  skin  is  due.  When  the  irradi- 
ated integument  is  covered  with  hair,  effluvium  capillorum  may 
be  observed  at  an  early  stage.  At  first  the  hair  becomes  loose  only, 
so  that  a  gentle  effort  suffices  to  pull  it  out.  This  early  symptom 
can  be  recognised  only  if  the  hair  is  not  cut  or  shaved  away  during 
the  period  of  treatment.  Erythema  due  to  irradiation  differs 
somewhat  from  the  ordinary  type.  It  resembles  the  form  of  ery- 
thema that  is  caused  by  sunburn.  Its  tints  are  light  at  first,  turn- 
ing into  a  diffuse  or  spotted  red-brown  later  on. 

A  resume  of  the  points  and  principles  emphasized  may  be  con- 
densed into  the  following  rules :  The  tubal  light  emanating  from 
the  anticathode  of  a  soft  tube  strikes  the  centre  of  the  area  to  be 
irradiated  at  a  distance  of  the  tubal  wall  from  the  skin  of  four 
inches  first,  later  on  it  is  gradually  decreased  to  one  inch.  In 
malignant  diseases  the  exposure  may  last  longer — that  is,  if  the  tis- 
sues do  not  react  after  an  exposure  of  ten  minutes,  they  may  be 
prolonged  to  fifteen,  and  in  obstinate  cases  may  be  intensified  by 
the  use  of  the  author's  diaphragm  (compare  Treatment  of  Ma- 
lignant Growths).  The  seances  are  repeated  every  second  or  third 
day,  and  if  no  reaction  shows,  daily,  until  the  desired  result  is 
accomplished  or  reaction  manifests  itself  in  the  shape  of  tumes- 
cence or  intumescence  of  the  skin.  Then  irradiation  must  be 
stopped  until  the  disappearance  of  these  symptoms.  The  patient's 
attention  must  be  called  to  the  fact  that  those  signs  as  well  as  the 
sensation  of  itching,  burning,  or  tension  may  occur  any  time 
during  treatment,  so  that  he  will  be  able  to  report  at  once  to  his 
physician.  An  induction  coil  giving  a  spark  length  of  10  to  15 
inches,  either  in  connection  with  an  accumulator  or  the  street 
current,  and  a  Wehnelt  interrupter  answers  all  therapeutic  pur- 
poses. An  amperage  of  2  to  3  is  used  on  an  average  for  non- 
malignant  affections. 


CHAPTEE    XIX 

SPUl  'JAL   INDIt  'A  TIONS 

The  first  methodical  experiments  in  the  treatment  of  hypertri- 
chosis were  made  by  Freund  and  Schiff.  The  production  of  an  in- 
flammatory process  in  the  integument,  observed  in  their  easts,  sug- 
gested the  use  of  the  Kontgen  rays  in  lupus.  Soon  afterward  fa- 
vourable results  were  reported  by  Kuemmell,  Albers-Schoenberg, 
Ziemssen,  Hahn,  Gocht,  Maclntyre,  Pratt,  Gilman,  and  the  author. 
While  at  the  present  time  the  experimental  stage  has  not  been 
passed,  yet  sufficient  evidence  of  the  effect  of  the  rays  is  accumu- 
lated now  in  hypertrichosis,  sycosis,  favus,  blepharitis,  alopecia, 
acne,  psoriasis,  eczema,  prurigo,  nsevus  vasculosus,  lupus,  carci- 
noma, and  sarcoma.  Even  in  Hodgkin's  disease,  rheumatism, 
tuberculosis,  and  neuralgia  favourable  results  are  reported. 


HYPEETEICHOSIS 

The  general  principles  emphasized  in  special  indications  hold 
good  in  the  treatment  of  hypertrichosis.  If  the  chin  or  the  cheeks 
are  to  be  irradiated,  the  head  must  be  thrown  far  back,  non- 
affected  areas  of  the  face  as  well  as  the  chest  are  protected  by  a 
lead  mask.  If  only  the  upper  lip  is  to  be  treated,  a  lead  mask 
covering  the  whole  face  is  chosen  and  an  opening  corresponding  to 
the  lip  is  cut  in  it.  The  rays  are  directed  vertically  on  the  area. 
After  the  tentative  exposures  (see  foregoing  chapters)  were  not 
followed  by  any  reaction,  the  diseased  area  is  irradiated  ten  min- 
utes on  three-day  intervals  at  a  distance  of  four  inches  (110  volts, 
3  amperes) .  Eeaction  takes  place  after  twelve  to  twenty  days,  the 
first  signs  being  light  red  or  brownish  decolourization  of  the  skin 
and  loosening  of  the  hair.  The  patient  feels  a  slight  burning  sen- 
sation. Further  treatment  is  stopped  now.  During  the  next  week 
the  hairs   fall  out   gradually.      If   left   alone   the   hair   is   again 

381 


382 


THE    RONTCIEN    RAYS 


restored  in  five  to  eight  weeks.  In  order  to  prevent  this  a  second 
course  of  irradiation  is  necessary.,  which  must  begin  four  weeks 
after  the  signs  of  reaction  have  disappeared,  this  time  only  four  to 
five  seances  being  necessary,  as  a  rule,  to  induce  a  lasting  alopecia. 
In  case  of  recurrence  the  same  mode  of  treatment  is  repeated. 

In  young  persons  reaction  is  more  rapid  and  intense  than  in 
middle-aged  people.  If  irradiation  was  continued  after  reaction 
was  well  marked,  teleangiectatic  areas  may  remain  (compare  Fig. 
264).  Disfiguration  of  this  kind  exchanged  for  hypertrichosis  is 
of  course  sorely  felt  by  the  patients,  who  generally  belong  to  the 
fair  sex.  The  growing  of  hair  on  skin-flaps  after  transplantation 
may  be  an  obstacle  for  complete  union,  so  that  the  result  of  the 

operation  may  be  jeopar- 
dized. In  an  event  of 
this  kind  depilation  by 
the  Rontgen  light  be- 
comes one  of  the  most 
important  healing  factors. 

SYKOSIS 

Where  blisters  and 
excoriations  are  present 
a  few  exposures  suffice  as 
a  rule.  As  soon  as  the 
diseased  area  assumes 
tints  of  darker  red  fur- 
ther treatment  is  to  be 
suspended.  The  princi- 
ples of  the  technique  are 
the  same  as  described  for 
hypertrichosis. 

Fig.  265  illustrates 
the  case  of  a  man  of 
thirty  years  who  had  been  treated  in  vain  for  several  years.  Fig. 
266  shows  the  remarkable  effect  of  one  exposure  of  ten  minutes  at 
a  distance  of  four  inches  a  week  afterward.  The  blisters  were 
dried  up  after  ten  days,  the  secretion  and  crust  formation  stopped, 
and  the  sensation  of  itching  and  tension  disappeared  a  few  hours 
after  irradiation. 


Pig.  265. — Sykosis.     (Compare  Fig.  248.) 


SPECIAL    INDICATION'S 


383 


After  three  to  four  weeks  a  recurrence  may  be  observed,  in  which 
case  short  irradiation  must  he  taken  up  again.     Sometimes,  how- 
ever, the  reaction  is  intense,  new  blisters  forming,  and  the  pain 
increasing.     In  an   event 
of    this    kind    irradiation 
must,    of    c  o  u  r  s  e,    he 
stopped,  and  warm  appli- 
cations  of   Burow's   solu- 
tion be  made. 

If  sykosis  localizes  at 
the  hair  follicles  only, 
small  red  nodules  de- 
veloping  ( f ollicu  1  i I i s 
barbae),  treatment  is  best 
continued  until  the  hair 
becomes  lessened  and 
falls  out.  By  eliminating 
the  hair  every  possible 
exciting  factor  is  re- 
moved from  cutis  and 
papilla?. 

In  order  to  control 
the  process  of  depilation. 
the  advice  must  be  given 
to  the  patient  to  leave  the 
hair  untouched,  and  espe- 
pecially  not  to  be  shaved. 

In   trichophytosis  (sykosis    parasitaria   hyphogenes)  the    same 
good  results  may  be  obtained  after  only  one  seance. 


Fig. 


266.— Case    of    Sykosis,    Illustrated 
by  Fig.  247  aftek  one  Exposure. 


FAVUS 


Favus  requires  the  most  energetic  treatment.  Complete  depila- 
tion of  the  skull  is  necessary  to  obtain  the  desired  effect.  To  this 
end  the  tube  is  placed  above  the  anterior  portion  of  the  skull  first, 
then  above  the  lateral  parts,  and  finally  over  the  middle  of  the 
occiput.  In  order  to  be  able  to  irradiate  as  large  an  area  as  pos- 
sible at  the  time,  the  distance  should  be  from  eight  to  ten  inches. 
The  seances  should  take  place  daily,  and  their  length  should  never 


384  THE    RONTGEN    RAYS 

be  less  than  ten  minutes.  Soft  tubes  are  used.  After  two  to  three 
weeks  the  integument  becomes  red  and  the  hair  begins  to  fall  out. 
The  curative  influence  of  the  rays  in  favus  does  not  seem  to  be  of 
a  bactericidal  nature,  since  the  vitality  of  the  parasites  found  after 
depilation  did  not  appear  to  be  impaired.  The  elimination  of 
the  hair,  which  may  be  viewed  as  a  kind  of  foreign  body,  permits 
of  extensive  removal  of  the  parasites,  which  are  sheltered  by  the 
roots  as  well  as  by  the  outer  follicular  tissues.  At  the  same  time 
degeneration  of  the  cellular  elements,  between  which  the  parasites 
propagate,  is  induced.  The  stimulatory  effect  of  nutrition  may 
also  be  regarded  an  important  factor  in  the  healing  process. 


BLEPHARITIS 

Schiff  and  Freund  reported  that  in  ulceration  and  squamous 
inflammatory  processes  of  the  lid-margins  four  to  nine  weak  ex- 
posures sufficed  to  separate  the  crusts.  The  excoriations  became 
covered  with  normal  skin  tissue  and  the  diffuse  reddening  dis- 
appeared. The  ciliae  did  not  fall  out  as  a  rule.  The  irradiation 
was  done  while  the  eyelids  were  closed. 


ALOPECIA    AREATA 

Kienboeck,  Holzknecht,  Freund,  Schiff,  and  Ehrmann  observed 
that  after  the  slight  quantity  of  hair  present  was  removed  by 
irradiating  new  liair  was  gradually  restored  in  much  larger  quanti- 
ties. The  irradiation  should  be  repeated  every  three  days  at  a 
distance  of  six  inches  (two  amperes),  and  must  not  last  longer  than 
six  minutes.  The  result  is  hardly  due  to  the  bactericidal  influence 
of  the  rays,  but  rather  to  the  stimulating  effect  of  weak  Rontgen 
light.  Tubes  of  medium  hardness  should  be  selected.  During  the 
intervals  10-per-cent  xeroform-lanolin  is  to  be  used.  In  young 
individuals  the  prognosis  is  favourable,  especially  if  there  be  only 
small  areas.  But  in  universal  alopecia  and  in  aged  persons  no  posi- 
tive results  could  be  reported  yet. 


SPECIAL    INDICATIONS  385 


ACNE    VULCAKIS    AM)    ROSACEA 

In  obstinate  oases  of  acne  irradiation  may  be  resorted  to.  Poki- 
tonoff  and  Gautier  reported  cures  in  17  cases  of  acne  vulgaris 
and  rosacea.  The  seances  took  place  daily  at  a  distance  of  7 
inches.  They  lasted  four  minutes  (-1  amperes  and  is  to  20  volts). 
After  the  sixth  exposure  the  pustules  and  vascularization  disap- 
peared. Similar  observations  were  made  by  Jutassy,  Eahn, 
Schiff,  and  Freund. 

It  seems  that  the  effect  is  less  due  to  the  bactericidal  properties 
of  the  rays  than  to  their  inhibiting  influence  on  the  secretion  of 
the  follicles.  Freund  believes  that  the  desquamation  of  the  epi- 
dermis, following  irradiation,  is  the  most  important  healing  factor. 


PSORIASIS 

Albers-Schoenberg  and  Flahn  reported  that  the  red  plaques 
became  lightened  up  after  four  to  five  stances,  and  that  at  the 
same  time  scales  could  be  pulled  off  without  the  characteristic 
bleeding.  Different  areas  were  exposed  during  one  sitting.  At 
first  irradiation  was  kept  up  daily,  after  the  third  exposure  every 
two,  later  every  third  day.  Freund  advised  an  exposure  of  ten 
to  twelve  minutes  at  a  distance  of  7  to  8  inches  if  the  affection 
is  of  a  diffuse  nature,  while  small  areas  require  only  four  minutes 
time  at  a  distance  of  4  to  5  inches.  Recurrence  takes  place  fre- 
quently, therefore  it  is  advisable  to  take  up  slight  irradiation  four 
weeks  after  recovery  for  a  short  period. 


ECZEMA 

Grunmach,  Hahn,  Ziemssen,  Jutassy,  and  Schiff  observed  ceas- 
ing of  the  exudation  in  acute  as  well  as  in  chronic  eczema,  after 
a  few  seances.  The  epidermis  peeled  off  and  the  itching  disap- 
peared. Irradiation,  however,  should,  just  as  in  psoriasis,  be  re- 
sorted to  only  in  such  cases,  where  the  well-tested  old  methods 
proved  to  be  inefficient.     The  therapeutic  technique  is  practically 

the  same  as  in  psoriasis. 
2G 


386  THE    RONTGEN    RAYS 


N^EVUS   VASCULOSIS    (FLAMMEUS) 

Jutassy  (Fortschritte  der  Rontgenstrahlen,  Band  ii,  Heft  5) 
reports  a  case  of  this  congenital  condition  in  which  a  perfect  cure 
was  obtained.  The  telangiectatic  area  occupied  the  right  half  of 
the  face  of  a  young  man.  The  exposures  lasted  four  and  a  half 
hours  in  all  during  six  days.  The  healthy  parts  of  the  face  were 
protected  by  a  lead  mask.  In  spite  of  this  most  energetic  treat- 
ment the  reaction  was  only  slight.  At  first  hyperemia  was  noticed 
around  the  diseased  area.  After  two  weeks  the  epidermis  peeled 
off  in  small  scales.  Three  weeks  after  the  last  exposure  the  nsevus 
had  become  paler.  A  more  severe  inflammation  was  produced 
then.  During  eleven  seances  the  tumorous  area  was  exposed  to 
intense  light  at  a  short  distance  for  ten  hours.  Twelve  days  after 
the  last  sitting  a  severe  dermatitis  developed,  apparently  of  the 
necrotic  type,  the  healing  of  which  took  two  months.  Then  the 
nsevus  had  disappeared. 

In  elephantiasis  and  urticaria  pigmentosa  good  results  were 
observed  by  Sorel  and  Toeroek. 


LUPUS   VULGARIS 

The  fact  that  lupus  vulgaris  is  curable  by  the  Rontgen  rays 
cannot  be  disputed  any  longer.  To  Kuemmel  belongs  the  credit 
for  advising  the  new  therapy  for  this  gravest  and  most  obstinate 
skin  affection  (Twenty-sixth  Congress  of  the  German  Surgical  So- 
ciety, 1897).  Later  on  Schiff,  Freund,  Albers-Schoenberg,  ISTeis- 
ser,  Gocht,  and  the  author  published  favourable  results.  The  ad- 
vice given  by  the  author  in  regard  to  ulcerative  processes — namely, 
to  remove  all  broken-down  tissue  by  the  scissors  or  the  sharp  spoon, 
if  it  can  be  easily  done,  before  irradiation  is  begun,  also  applies 
to  the  treatment  of  lupus.  The  final  result  is  obtained  more 
quickly  and  safely  then.  Whatever  can  be  clone  better  and  more 
efficient  by  the  scalpel  or  the  cautery  should  not  be  left  to  the  rays. 
Thus  slight  operative  interference,  followed  by  irradiation,  often 
represents  a  happy  combination.  When  no  detritus  is  present, 
irradiation  is  started  without  resorting  to  any  preliminary  pro- 
cedures. 


SPECIAL   INDICATIONS  387 

No  tentative  exposures  are  required.  The  sittings  should  not 
last  longer  than  fifteen  minutes  at  a  distance  of  4  inches  for  the 
first  6  seances,  and  then  of  2  inches  only.  They  may  be  repeated 
daily  until  reaction  shows.  The  Rontgen  light  should  be  intense, 
a  tube  of  medium  hardness  being  best  selected  (4  amperes  at  110 
volts).  Mucous  membranes  are  irradiated  through  Ferguson  spec- 
ula, the  interior  of  which  is  lined  with  lead.  Into  the  nose  a 
special  speculum  of  this  kind  must  be  introduced.  As  soon  as  reac- 
tion is  observed,  the  signs  of  which  are  dark  swelling  of  the  lupus 
area  and  reddening  of  the  nodules,  the  treatment  is  temporarily 
stopped.  If  the  mucous  membrane  is  concerned,  the  first  symptom 
of  reaction  consists  in  a  marked  increase  of  the  secretion.  As  a 
rule  the  ulcerated  portions  cicatrize  then,  the  scabs  dry  up  and 
fall  off,  and  the  skin  is  peeling.  The  nodules  shrink,  the  hyper- 
emia disappears,  and  whitish  scar-tissue  forms.  Four  weeks  after 
apparent  recovery  slight  irradiation  must  be  taken  up  again  for  a 
short  period  in  order  to  prevent  recurrence.  It  is  the  neglect  of  this 
precaution  which  is  mainly  responsible  for  the  speedy  recurrence 
reported  by  various  observers.  During  the  intervals  10-per-cent 
xeroform-lanolin  is  applied  to  the  diseased  area.  Before  irradia- 
tion the  ointment  is  carefully  removed  again. 

The  process  of  healing  seems  to  be  induced  by  the  degeneration 
of  the  cellular  elements,  especially  of  the  giant  and  epithelioid 
cells  of  the  nodules,  followed  by  inflammatory  reaction  and  hyper- 
emia. That  hyperemia  is  a  most  important  factor  in  the  cure  of 
tuberculosis  was  demonstrated  by  Eokitansky  more  than  fifty  years 
ago.  It  presents  in  fact  the  most  unfavourable  condition  for  the 
development  of  tuberculosis.  This  dictum  is  corroborated  by  the 
observation  that  tuberculosis  of  the  lungs  rarely  occurs  if  there 
are  congestion  processes  in  the  thoracic  organs  (heart  lesions, 
asthma,  etc.). 

The  favourable  influence  of  artificial  hyperemia  in  tubercu- 
losis of  joints  was  proved  by  Bier.  On  the  other  hand,  clinical 
observation  shows  that  anemia  offers  the  most  favourable  condi- 
tion for  the  development  of  tuberculosis,  therefore  it  must  be 
combated  energetically.  Those  biologic  considerations  should  not 
be  lost  sight  of  when  we  try  to  understand  the  mode  of  healing. 
(Compare  chapter  on  Physiological  Effects  of  the  Rontgen  Rays 
above.) 

Lupous  tissue,  removed  after  irradiation,  shows  the  homoge- 


388 


THE    KONTGEN"    EAYS 


neous  epithelium  permeated  by  very  small  openings  on  microscop- 
ical examination.  The  corium  tissue  as  well  as  the  cells  of  the  con- 
nective tissues  appear  to  be  shrinking.  The  giant  cells  as  well 
as  the  epithelioid  cells  are  of  smaller  size  and  have  lost  their  nor- 
mal shape,  so  that  they  also  show  a  shrinking  and  homogeneous 
appearance.  This  indicates  that  epithelium,  a  part  of  the  corium, 
and  the  lupous  nodules  gradually  become  necrotic  and  dry  up 
finally. 

Fig.  267  illustrates  the  case  of  an  Armenian  of  thirty  years  who 
suffered  from  lupus  vulgaris  of  nose  and  face  since  eleven  years. 
He  was  always  under  medical  care.  Two  years  before  irradiation 
was  begun,  extirpation  of  the  nodules  had  been  undertaken.  This 
was  followed  by  great  temporary  relief,  but  the  lupous  areas  in 

both  nostrils  resisted  the 
therapy,  which  consisted 
mainly  in  the  application 
of  caustics.  At  the  time 
the  Rontgen-ray  treat- 
ment was  begun  extensive 
recurrence  had  taken 
place.  Irradiation  was 
started  in  a  tentative 
manner — that  is,  first  an 
exposure  of  ten  minutes 
was  given  at  a  distance 
of  4  inches  (4  amperes 
at  110  volts).  The  sec- 
ond sitting  took  place  a 
week  afterward,  and  the 
third  after  another  week 
in  the  same  manner. 

No    reaction    showing 
after     the    tentative     ex- 
posures,   irradiation    was 
tried  every  second  day  for 
ten    minutes.     After    the 
eighteenth     exposure    ex- 
coriations   appeared,    therefore    the    seances    were    discontinued. 
The    dermatitis    healed    in    two    weeks,    and    with    the    excep- 
tion  of  the   intranasal   nodules   all   signs   of    lupus   had   disap- 


Fig.  267.— Lupus  Simplex. 
(Compare  Fig.  268.) 


SPECIAL    INDICATIONS 


389 


peared  with  it.  Irradiation  was  taken  up  now  in  a  more  ener- 
getic manner,  the  sittings  taking  place  daily  a!  a  distance  of  an 
inch  only  and  lasting  fifteen  minutes.  \o  protection  was  used 
except  that  the  eyes  were 
kept  closed.  After  the 
eighth  irradiation  intense 
dermatitis  set  in.  At  the 
distant  areas  the  inllain- 
matron  was  of  the  second 
and  at  the  upper  lip  of 
the  third  degree.  The 
face  was  held  upward,  so 
that  the  rays  could  reach 
the  intranasal  nodules. 
Under  warm  applications 
of  Burow's  solution  the 
reaction  disappeared  in 
three  weeks.  During  the 
after  -  treatment  salicyl- 
lanolin  (1  per  cent)  was 
employed.  Four  weeks  af- 
ter the  reaction  had  set  in 
recovery  was  perfect.  The 
intranasal  nodules  were 
cicatrized.  Fig.  268  shows 
the  result  of  cicatrization, 
one  of  its  effects  being  the 
narrowing  of  the  left  nos- 
tril. The  patient  was  irradiated  again  six  times  in  the  same  man- 
ner in  which  he  was  treated  at  first.  No  recurrence  was  observed. 
If  a  mask  is  used,  gauze  covered  with  five  thicknesses  of  tinfoil 
is  best  selected  into  which  a  hole  corresponding  with  the  part 
irradiated  is  cut.  The  mask  is  fastened  to  the  head  by  a  bandage. 
A  considerable  portion  of  the  healthy  tissue  must,  however,  always 
be  left  free. 

LUPITS    EEYTHEMATODES 

Hahn,  Schiff,  Scholtz,  Jutassy,  Woods,  Taylor,  and  the  author 
reported  the  most  satisfactory  results.  In  most  cases,  however, 
speedy  recurrence  was  observed,  which  yielded  only  to  repeated  ex- 


Fig.  268. — Case  of  Lupus  Simplex,  Illus- 
trated bit  Fig.  267,  Cured  by  Irradi- 
ation. 


390 


THE    RONTGEN    RAYS 


posures.  Otherwise  the  mode  of  treatment  is  the  same  as  in  lupus 
vulgaris.  The  reaction  causes  hypersemia  and  swelling,  followed 
by  exudation  and  crust-formation. 

Fig.  269  illustrates  the  case  of  a  woman  of  twenty-four  years 
who  suffered  from  lupus  erythematodes  nasi  et  faciei  since  she  was 
five  years  old.  The  facial  lesion  had  the  appearance  of  a  butterfly. 
Although  being  treated  with  caustics  and  the  Paquelin's  cautery 
the  disease  was  disseminated.  The  patient  gave  a  history  of  tuber- 
culosis. A  brother  as  well  as  a  sister  died  from  pulmonary  tuber- 
culosis. She  had  three 
children,  one  of  which 
was  still-born,  and  an- 
other died  from  menin- 
gitis (tuberculous).  The 
third  is  healthy.  No 
tentative  exposures  were 
given.  Irradiation  was 
tried  every  second  day 
for  ten  minutes  at  a  dis- 
tance of  an  inch.  A  soft 
tube  was  selected.  After 
the  fifteenth  exposure  the 
infiltration  began  to  dis- 
appear. After  the  twen- 
tieth exposure  the  crusts 
came  off  and  the  nodules 
showed  the  signs  of 
shrinking.  After  the 
twenty-fifth  exposure  the 
nodules  had  disappeared, 
the  skin  appeared  smooth 
(Fig.  270).  For  six 
after-treatment  consisted  in 


Fig. 


269.— Lupus  Erythematodes. 
(Compare  Fig.   270.) 


weeks  slight  redness  persisted.     The 
tbe  application  of  salicyl-lanolin. 


CARCINOMA 

The  treatment  of  external  forms  of  carcinoma,  including  those 
of  breast,  tongue,  and  cervix  uteri,  by  the  Rontgen  rays  has  become 
a  recognised  method.    In  fact,  all  integumental  types  are  accessible 


SI'KCIAL    INDICATIONS 


391 


to  Bontgen-ray  therapy.  In  the  deep-seated  forms  the  strength  of 
the  rays  decreases  so  much  that  only  a  limited  influence  is  exerted. 
There  is,  of  course,  a 
regressive  metamorphosis 
observed  in  the  deeper  tis- 
sues of  the  body,  but  only 
under  extremely  favoura- 
ble circumstances  a  cure 
would  be  expected.  That 
even  carcinoma  of  the 
stomach,  liver,  or  of  the 
corpus  uteri  may  be  influ- 
enced is  not  denied,  but 
such  influence  is  not  in- 
tense enough  to  prom- 
ise more  than  a  slight 
amelioration.  Ne  quid 
n  i  m  i  s  !  Extravagant 
promises  will  discredit  the 
new  and  delicate  field 
of  Bontgotherapy.  In 
spite  of  the  fact,  how- 
ever, that  integumental 
carcinoma  yields  to  the 
Eontgen  therapy,  the 
author  would  regard  it  ex- 
tremely unwise  to  leave  to  the  rays  what  can  be  done  much  quicker 
and  more  effectively  with  the  scalpel — namely,  extensive  removal. 
But  irradiation  should  be  considered  in  the  after-treatment  as 
well  as  in  inoperable  cases.  Even  after  a  thorough  operation  of 
carcinoma,  cells  are  often  left  in  the  deeper  strata  which  cannot 
be  reached  by  the  surgical  knife.  We  must  consider  that  in  the 
majority  of  cases  the  recurrence  of  carcinoma  is  caused  by  the  epi- 
thelial cells  of  the  primarily  affected  area,  and  but  rarely  by  those 
of  the  secondary  foci.  Local  recurrence,  the  most  frequent  form, 
is  always  produced  by  the  carcinomatous  cells  which  were  left  back, 
at  the  operation,  while  the  indirect  type  originates  from  neighbour- 
ing tissue,  which  at  the  time  of  the  operation  appeared  to  be  nor- 
mal, but  in  fact  carried  the  embryonic  elements  of  carcinomatous 
infection. 


Fig.  270. — Case  of  Lupus  Erythematodes, 
illustrated  by  flg.  269,  cured  by  ir- 
RADIATION.     (Compare  Fig.  2C9.) 


392  THE    EONTGEN    EAYS 

A  carcinomatous  portion,  however,  left  at  the  time  of  operation 
must  not  necessarily  always  be  the  cause  of  further  infection.  The 
vis  medicatrix  natures,  often  attempts  to  secure  a  natural  protection 
by  surrounding  the  cancer  alveoli  with  giant  cells,  which,  as  micro- 
scopical examination  shows,  starts  a  regressive  metamorphosis 
analogous  to  the  well-known  healing  processes  in  tuberculosis.  It 
is  the  abundance  of  the  epithelial  toxines  which  prepares  the  soil 
for  the  new  invasion  and  further  development  of  the  carcinoma 
cells.  This  also  explains  the  rare  occurrence  of  blood  metastasis 
in  carcinoma.  If  these  cells  could  not  really  be  destroyed,  but  if 
only  a  regressive  metamorphosis  was  induced  by  the  rays,  a  great 
advance  in  the  treatment  of  this  horrible  disease  would  be  made. 
The  pioneer  work  in  this  direction  was  done  in  the  United  States, 
Gilman,  Williams,  Pusey,  Grubbe,  Morton,  Allen,  Johnson,  Skinner, 
and  the  author  having  been  early  advocates  of  the  new  method  in 
carcinoma.  As  a  rule  the  induration  disappeared  after  15  to  30 
seances.  Crusts  disappeared  and  cicatrization  of  ulcerated  areas 
began.  In  epithelioma  {ulcus  roclens)  the  hard  margins  of  the 
ulcerated  area  soften,  the  adjacent  tissues  becoming  erythematous. 
Later  on  granulations  appear  on  the  surface  of  the  ulcus,  which 
brings  it  on  a  level  with  the  normal  integument.  Epidermization 
soon  follows  then.  The  subjective  condition  often  improved  after 
one  exposure.  In  fact,  one  of  the  most  striking  signs  of  improve- 
ment was  the  prompt  relief  from  pain.  Truly,  if  the  rays  would 
do  no  more  than  to  give  relief,  where  strong  narcotics  failed,  they 
would  be  a  blessing.  Microscopical  examination  shows  gradual 
destruction  of  the  epithelial  cells.  Nucleus  and  protoplasm  un- 
dergo lysis.  In  some  cells  fatty  degeneration  is  observed.  At  the 
same  time  there  is  a  stimulatory  effect  on  the  connective-tissue 
elements. 

In  the  exposures  examined  by  the  author,  the  irradiated  areas 
showed  colloid  degeneration,  the  character  of  the  tumorous  texture 
having  disappeared.  It  seems  that  this  colloid  change  is  character- 
istic for  the  mode  of  cell-metamorphosis  after  irradiation.  Fig. 
271  shows  the  tumourous  area  in  adenocarcinoma  of  the  breast 
before  irradiation,  while  Fig.  272  demonstrates  the  same  area  after 
slight  reaction  had  set  in.  In  the  latter  colloid  degeneration  is 
beginning.  A  resemblance  to  glandular  structure  is  shown.  In 
most  parts  the  alveoli  are  completely  filled  with  epithelial  cells,  so 
that  in  some  places  they  appear  like  alveolar  carcinoma,     Some 


SPECIAL    INDICATIONS 


393 


areas  have  undergone  degeneration,  their  epithelial  cells  no!  taking 

on  the  stain  the  same  as  others.  The  cells  have  diminished  in  size 
and  the  degenerated  area,  excepi  the  nuclei,  appears  coarsely  gran- 
ular. Changes  of  the  same  nature  arc  observed  in  the  epithelium  of 
the  skin  covering  the  tumour  (also  due  to  the  action  of  the  rays). 
In  some  parts  of  the  necrotic  area  a  large  amounl  of  dense  con- 
nective tissue  and  marked  vascularity  are  noticed. 

In  the  treatment  of  the  skin  diseases  described  above,  tentative 
exposures,  and  protection  of  the  vicinity  of  the  affected  area  were 


Pig.  271. — Carcinomatous  Area,  not  affected  by  the  Rays. 
(Compare  Fig  272.) 


advised.  The  distance  of  the  tube  was  not  less  than  4  inches  in 
the  beginning,  the  duration  ten  minutes,  and  the  intervals  two  to 
three  clays  on  an  average. 

In  treating  malignant  diseases  we  should  be  governed  by  entire- 
ly different  principles.  The  author  has  emphasized  repeatedly  that 
nothing  appears  more  absurd  than  protecting  the  area  which  de- 
mands the  influence  of  a  sort  of  destroying  agent.  Since  Volkmann 
found,  on  microscopical  examination,  that  even  in  small  and  super- 
ficially located  carcinomatous  growths  of  the  mammary  gland,  the 


394  THE    EONTGEK    EAYS 

fascia  was  generally  involved,  he  was  naturally  led  to  the  conclu- 
sion that  removal  of  the  tumour  alone  was  an  insufficient  pro- 
cedure. The  correctness  of  his  investigations  was  corroborated  by 
Heidenhain,  who  found  carcinomatous  cells  in  the  superficial 
layer  of  the  pectoralis  major  muscle,  even  when  the  breast  was 
only  superficially  involved.  From  these  observations  we  learned 
that,  at  least,  the  superficial  layer  of  the  pectoralis  major  muscle 


Fig.  272 — Carcinomatous  Area  after  Irradiation,  Showing  Colloid  Degen- 
eration.    (Compare  Pig.  271.) 

should  be  dissected  away  in  all  cases,  when  the  carcinomatous  nod- 
ule was  but  of  small  size. 

It  did  not  take  long  for  the  conclusions  of  Volkmann  and 
Heidenhain  to  bear  rich  fruits.  The  surgeons  who  followed 
Volkmann's  example  were  soon  able  to  report  cases  which  showed 
no  signs  of  recurrence  until  after  more  than  a  year.  Kuester,  Senn, 
Halsted,  Weir,  Meyer,  and  the  author  (Medical  Society  of  the 
County  of  New  York,  November,  1892)  advised  still  more  radical 
steps,  with  more  or  less  modification  of  the  original  method. 

The  motto  "  Better  too  much  than  too  little  "  must  be  adhered 
to  in  malignant  disease,  as  emphasized  in  the  author's  previous 


SPECIAL    INDICATIONS  395 

publications.  It  is  better,  therefore,  to  suffer  from  sligbt  func- 
tional disturbances  after  sacrificing  the  whole  pectoralis  major  and 
minor  muscles  than  to  attain  a  good  functional  result  followed  by 
speedy  recurrence. 

Even  if  a  limited  area  is  involved  only,  as  in  the  case  illus- 
trated by  Fig.  275,  a  most  extensive  removal  is  required. 

Now,  if  we  are  convinced  of  the  fact  that,  even  when  there  is 
only  a  small  carcinomatous  nodule  in.  the  mammary  gland,  the 
superficial  layer  of  the  pectoralis  major  muscle  contains,  or  may 
contain,  carcinoma  cells,  why  restrict  ourselves  then,  if  we  attempt 
to  treat  a  nodule  of  this  kind  by  the  Rontgen  rays?  Is  it  not 
exactly  the  contrary  of  what  we  wish  to  achieve,  if  we  then  pre- 
vent distant  carcinoma  cells  from  being  reached  by  covering  the 
vicinity  with  some  impermeable  metal?  We  want  to  reach  all  car- 
cinoma cells  if  we  can,  and  the  so-called  shield  does  not  shield  the 
patient,  but  the  carcinoma  cells.  Therefore,  shields  off  in  malig- 
nant disease !  If  we  have  made  up  our  mind  to  influence  the  carci- 
noma cells,  we  must  employ  sufficient  energy  to  enforce  this  result. 

This  does  not  imply,  however,  that  the  other  extreme  should 
be  striven  for.  We  must  follow  our  therapeutic  strategy  in  a 
determined  but  carefully  observant  manner.  The  practical  modus 
operandi  is,  therefore,  about  the  following: 

The  patient  suffering  from  malignant  disease  is  irradiated 
without  first  submitting  to  tentative  exposures.  The  tube  should 
be  as  near  the  tumorous  area  as  possible,  the  distance  of  the  tubal 
wall  from  the  skin  never  exceeding  2  inches. 

This  is  done  for  the  purpose  of  influencing  the  growth  itself 
as  powerfully  as  possible.  After  there  is  a  slight  erythematous 
reaction,  within  the  immediate  vicinity  of  the  growth,  the  distance 
is  increased  for  the  following  seance.  Thus  the  rays  reach  a  larger 
surface.  In  mammary  carcinoma,  for  instance,  the  area  between 
the  sternum  and  axilla  must  be  fully  exposed.  When  this  wider 
field  becomes  erythematous  also,  the  irradiation  must  be  stopped 
for  a  few  days  until  it  shows  signs  of  disappearance.  It  is  not 
advisable  to  wait  until  the  last  little  sign  of  dermatitis  has  van- 
ished, because  much  valuable  time  may  be  lost  by  waiting.  Re- 
peated attacks  of  dermatitis  may  thus  be  endured. 

It  seems  to  the  author  that  the  further  the  carcinomatous  infil- 
tration has  extended,  the  more  resistance  to  dermatitis  exists,  and 
consequently  the  less  reaction  takes  place,  the  cell-metamorphosis 


396  THE    KOXTGEN    RAYS 

lowering  the  irritability  of  the  skin.  This  non-susceptibility,  of 
course,  varies  with  the  different  types  of  malignancy.  It  seems  to 
be  greatest  in  the  fibrous  variety  of  carcinoma. 

In  severe  cases  and  when  there  is  little  reaction  the  author's 
diaphragm  may  be  used  in  order  to  concentrate  the  rays  on  the 
tumorous  area.     (Fig.  25.) 

If  there  be  extensive  ulceration,  causing  retention  of  pus,  irra- 
diation should  not  be  continued  until  the  area  is  exposed  fully, 
and  any  necrotic  tissue  removed  by  the  scalpel  or  sharp  spoon. 
If  this  is  omitted,  the  power  of  the  rays  is  not  only  inhibited,  but 
at  the  same  time,  toxaemia  from  local  decomposition  is  added  to 
cachexia,  a  very  dangerous  association,  indeed. 

If  the  integument  is  concerned,  soft  tubes  must  be  employed, 
but  deeper  infiltration  requires  tubes  of  medium  hardness.  It  is 
obvious  that  for  very  deep-seated  growths  hard  tubes  should  be 
employed,  in  vieAv  of  their  greater  penetration  power.  But  the 
rays  do  not  in  their  present  capacity  possess  so  much  force  in  the 
deeper  tissues  of  the  body  as  to  induce  a  complete  regressive  meta- 
morphosis. 

The  author  does  not  maintain  that  the  production  of  dermatitis 
in  the  treatment  of  malignant  disease  is  desirable  or  a  conditio 
sine  qua  non.  But,  with  our  present  means,  he  regards  powerful 
and  long  irradiation  a  necessity,  and  this,  unfortunately,  entails 
the  provocation  of  the  dermatitis. 

The  author's  experience  shows  that  whenever  a  dermatitis  has 
appeared  the  size  of  the  growth  has  diminished,  oedema  and  pain 
have  decreased,  and  the  general  condition  of  the  patient  has  im- 
proved. 

In  spite  of  extensive  dermatitis,  which  causes  a  most  distressing 
burning  and  itching  sensation,  all  patients  suffering  from  malig- 
nant disease  were  anxious  to  undergo  irradiation  again  as  soon  as 
possible.  If  the  raison  d'etre  is  thoroughly  explained  to  the  pa- 
tients, they  will  certainly  not  make  their  physicians  responsible  for 
excessive  burns.  A  patient  afflicted  with  carcinoma,  especially 
if  it  is  inoperable,  has  indeed  nothing  to  lose,  and  can  well 
afford  the  risk  of  being  burned.  Will  he  act  like  the  boy  who 
threw  rotten  eggs  at  the  man  who  pulled  him  out  of  the  water 
and  saved  him  from  drowning,  because  in  doing  so  he  had  pulled 
out  a  lock  of  hair  ?  And  in  any  case  the  physician  is  a  soldier  and 
must  do  his  duty  unconcerned,  whether  he  is  applauded  or  insulted. 


SPECIAL    INDICATIONS 


397 


Of  course,  the  purely  cosmetic  standpoint  is  entirely  different. 
If  dermatitis,  as  alluded  to  above,  occurs  in  the  face  of  a  Pair  lady, 
who  simply  wanted  to  be  treated  For  hypertrichosis,  the  cure  proves 
to  be  worse  than  the  disease. 

As  a  rule  a  seance  of  ten  minutes,  repeated  every  second  or 
third  day,  suffices.      Extensive  and  deeper-seated  growths  should 
be  irradiated  daily  for  the 
same  length  of  time,  and 
if  no  intense  reaction  ap- 
pears, for  twenty  minutes. 

As  soon  as  improve- 
ment is  noted,  the  expo- 
sures should  for  a  while  be 
shorter  and  the  intervals 
longer.  Six  weeks  after 
recovery  irradiation  must 
be  taken  up  again  for  a 
short  period.  The  views 
of  Volkmann  and  Heiden- 
hain  are  strikingly  illus- 
trated by  the  observation 
of  the  two  following  eases  : 

Fig.  273  illustrates  a 
patient  of  ninety-one  years 
of  age  who  suffered  from 
epithelioma  of  the  eyelid 
for  four  years.  He  was 
treated  chemically,  espe- 
cially with  caustics.     No 

attempt  at  excision  was  ever  made.  The  patient  was  greatly  dis- 
turbed by  the  excruciating  pain  in  and  around  the  deep  ulcer.  All 
efforts  to  give  relief  proved  to  be  failures  until  an  attempt  was 
made  with  the  Rontgen  rays.  After  the  first  exposure,  which 
lasted  five  minutes,  the  pain  was  considerably  lessened,  and  after 
the  second  exposure,  two  days  thereafter,  it  disappeared  entirely. 
N"o  protection  was  given,  except  that  the  patient  closed  his  eyes 
during  the  seance.  Sometimes  the  distance  of  the  tubal  wall  from 
the  skin  was  not  more  than  half  an  inch. 

Although,  after  the  nineteenth  exposure,  slight  erythema  de- 
veloped, the  seances  were  not  stopped  until,  after  the  twenty-sec- 


FlG. 


273. — Epithelioma  of  Lower   Lid  and 
Canthus.     (Compare  Fig.  274) 


398 


THE    RONTGEN    RAYS 


ond,  painful  dermatitis  showed  over  the  face.  Further  irradia- 
tion was  stopped  then  for  two  weeks,  when  all  signs  had  disap- 
peared. The  remainder  of  the  ulcer  was  dusted  with  xeroform, 
which  was  also  used  in  the  intervals.  After  three  more  exposures 
the  epithelioma  had  fully  cicatrized  (Fig.  274).  At  the  same 
time  an  epithelioma  showed  its  first  signs  at  the  lower  lip.    It  is  at 

present  being  treated  with 
Rontgen  light.  The  eye 
is  in  no  way  affected. 

It  must  be  assumed 
that  while  the  macroscop- 
ical  evidence  of  carci- 
noma was  concentrated 
upon  the  eyelid,  the  cells 
must  have  been  spread 
around  the  lymph-vessels 
of  the  whole  face,  thus, 
finally,  establishing  a 
focus  in  the  lower  lip. 

The  case  illustrated  by 
Figs.  275  and  276  is 
analogous.  It  concerns  a 
man  of  fifty  years,  whose 
epithelioma  of  the  lower 
lip  (Fig.  275)  was  cured, 
no  signs  of  recurrence 
showing  until  eighteen 
months  afterward.  Then 
a  small  nodule  appeared 
in  the  left  submaxillary 
region,  the  removal  of  which  was  refused  by  the  obstinate 
patient.  No  treatment  of  any  kind  was  submitted  to  until  the 
tumour  reached  the  size  illustrated  by  Fig.  276.  It  extended 
then  from  the  genio-hyoglossus  muscle  up  to  the  parotid  gland. 
As  could  be  ascertained  by  skiagraphy,  as  well  as  by  subsequent 
resection,  the  bone  showed  slight  erosion  at  its  lower  anterior  bor- 
der. The  microscopical  examination,  made  by  Dr.  R.  H.  Buxton, 
revealed  the  presence  of  a  large  number  of  cell  nests  in  the  epi- 
thelioma. An  extensive  operation  consisting  in  the  exsection  of 
the  left  half  of  the  mandible  and  removal  of  the  parotid  gland,  the 


Fig.     274.— Case     of 

TRATED      BY       FlG. 
DIATION. 


Epithelioma,     illus- 
273,   Cured   by    Irra- 


SPECIAL    INDICATIONS 


399 


Fig.   275. — Epithelioma,  of  Lower  Lip. 
(Compare  Fig.  276.) 


temporal,  the  masseter,  and 
the  sterno-cleido-mastoid  mus- 
cles was  done.  Recovery  was 
uninterrupted. 

Fig.  277  illustrates  analo- 
gous conditions.  The  patient's 
breast  was  amputated  by  the 
author  for  fibrocarcinoma. 
Two  years  afterward  a  carcino- 
matous growth  appeared  in  the 
inguinal  region,  while  the  area 
of  mammary  amputation  re- 
mained normal. 

From  the  observations  of 
the  case  illustrated  by  Figs. 
278  and  279  valuable  informa- 
tion  can   be   gained.     At   the 

time  the  patient  was  presented  to  the  American  Therapeutic  So- 
ciety, May  15,  1902,  she  was  fifty-nine  years  old.  She  began  to 
suffer  from  carcinoma  of  the  breast  ten  years  before.     After  having 

been  operated  upon  ten  times 
she  enjoyed  fairly  good  health 
(Fig.  278).  The  result  of  the 
author's  first  operation,  per- 
formed in  February,  1894,  was 
illustrated  in  the  Clinical 
Recorder,  October,  1896  (Fig. 
279). 

She  had  not  asked  medical 
advice  until  a  year  after  the 
first  signs  had  shown  them- 
selves. There  was  an  exten- 
sive carcinomatous  area  then 
of  the  left  breast,  the  axillary 
glands  also  being  involved. 
The  extensive  destruction  and 
the  pain  appealed  to   her   at 

last.      It    is   self-evident   that 
Fig.    276.— Carcinomatous      Tumor    of  -,         ,,  ,-, 

Inferior     Maxilla    and    Submaxil-     under    the    Circumstances    the 
art  Tissues.    (Compare  Fig.  275.)  author  had  to  perform  a  very 


400 


THE    RONTGEN    RAYS 


extensive  operation,  not  only  removing  the  pectoralis  major  mus- 
cle, together  with  the  axillary  glands,  but  also  exsecting  so  large  an 
area  of  adjacent  integument  that  a  plastic  operation  had  to  be 

undertaken  (see  Fig. 
279).  Recovery  was  per- 
fect until  six  months 
later,  when  a  small  nodule 
appeared  at  the  anterior 
axillary  fold.  This  was 
again  extensively  re- 
moved. Then  a  period  of 
euphoria  followed  for  a 
whole  year.  In  Septem- 
ber, 1896,  a  hard  nodule 
originated  near  the  ster- 
num, which  was  also  ex- 
tirpated. Then  there  was 
no  disturbance  until 
June,  1897,  when  a  small 
nodule  appeared  in  the 
axilla,  which  was  extir- 
pated by  Dr.  F.  Torek,  to 
whom  the  author  is  in- 
debted for  the  following 
report : 

On  August  7,  1897, 
there  was  a  pain  at  the 
site  of  the  past  operation.  No  recurrence.  March  7,  1898,  recur- 
rence in  posterior  axillary  line;  extirpation  April  11,  1899 ;  another 
recurrence,  the  tumour  showing  about  3  centimetres  in  diameter; 
ichthyol-vasogen  treatment.  On  January  16,  1900,  the  immovable 
tumour  has  grown  to  the  size  of  8  to  9  centimetres  in  diameter. 
Dissection  of  axillary  artery  and  ligation  of  the  axillary  vein. 
Microscopical  examination  by  Prof.  Henry  J.  Brooks ;  carcinoma, 
with  much  fibrous  tissue.  February  14th.  wound  perfectly  healed. 
February  14,  1901,  another  recurrence  in  axilla,  tumour  being 
about  the  size  of  an  egg.  February  19th,  operation.  Discharged 
from  hospital  cured  March  8th.  August  21,  1901.  another  large 
node,  probably  starting  from  the  stump  of  the  pectoralis  major 
muscle,  is  removed.     Primary  union.     October  31,  1901,  another 


Pig.  277. — Carcinomatous  Growth  in  the 
Inguinal  Region,  two  years  after  Re- 
moval of  Mammae. 


SPECIAL    INDICATIONS 


mi 


operation  is  made  in  the  pectoral  region,  and  two  nodules  removed 
in  the  axillary  region.  January  l.'i.  1902,  another  recurrence  in  the 
axilla  of  the  size  of  a  filbert;  also  one  tumour  below  the  clavicle, 
of  the  size  of  a  walnut.  A  third  neoplasm  is  observed  in  the  left 
arm.  in  the  former  region  of  the  pectoralis  major  muscle,  and 
alongside  the  biceps  muscle.  None  of  the  recurrent  tumours  is 
movable.  Medication :  Thyreoid  extract.  In  view  of  this  enor- 
mous extent  of  the  growths,  the  arm  also  being  extremely  ©edema- 
tous, a  tenth  operation  seemed  to  be  inopportune,  therefore  the 
Eontgen  therapy  was  considered  now. 

Still,  it  seemed  to  be  more  preferable  to  extirpate  the  tumour- 
ous  portions,  as  far  as  it  was  possible,  before  resorting  to  irradia- 
tion. The  author  succeeded  in  removing  the  whole  biceps  muscle, 
and  a  part  of  the  axillary 
region. 

The  infraclavicular 
tumour  could  not  be  re- 
moved in  its  entirety. 
The  patient  left  St. 
Mark's  Hospital  eleven 
days  afterward.  The 
general  condition  had  re- 
markably improved  after 
ten  irradiations,  each  one 
lasting  about  thirty  min- 
utes. The  infiltration  be- 
low the  clavicle  and  along 
the  triceps  muscle,  as  well 
as  the  oedema,  did  not 
disappear  until  extensive 
dermatitis  of  the  first  de- 
gree had  set  in. 

In  spite  of  its  imper- 
fect recovery,  this  case 
must  be  regarded  a  tri- 
umph of  surgery.  Ten 
years  have  now  elapsed  since  the  first  sign  of  carcinoma  was  ob- 
served, and  nearly  eight  years  since  the  first  operation,  which  was 
performed  under  the  most  unfavourable  circumstances,  due  to  the 
patient's  own   procrastination.      The   patient   still   appears   well. 


Fig.  278. — Carcinoma  Mammj;  after  Oper- 
ation for  Ninth  Recurrence.  (Compare 
Fig.  279.) 


402 


THE    KOFTGEN    RAYS 


The  author  expects  no  recovery,  but  believes  that  under  the  Eont- 
gen  treatment  her  condition  will,  at  least  temporarily,  improve 
further. 

Another  case,  also  presented  to  the  Therapeutic  Society,  may 
be  mentioned  in  view  of  a  few  interesting  peculiarities.    It  was  one 

of  adenocarcinoma  of  the 
breast,  recurring  three 
months  after  the  most  skil- 
ful removal. 

Within  another  three 
months  a  large  infiltrated 
mass,  reaching  from  the 
sternum  to  the  axilla,  had 
formed.  The  supraclavic- 
ular region,  the  shoulder, 
and  the  whole  upper  ex- 
JjF^  tremity    of    that    side   were 

^gr  ceclematous    to    the    utmost 

m^  degree.     Near  the  sternum  a 

small  ulcerating  area  was 
noticed.  The  patient  suf- 
fered temporary  pain  of 
great  intensity.  The  hus- 
band was  told  then  that 
there  was  hardly  a  possible 
chance  even  of  improve- 
ment, but  he  urged  the 
author  to  try  irradiation 
nevertheless.  The  whole 
area  was  exposed,  first  at 
intervals,  and  then  every 
day,  for  an  average  of 
twenty  minutes.  There  were  sixteen  exposures  altogether  before 
the  presentation.  After  the  fourteenth  exposure  the  infiltrated 
area  began  to  shrink  and  the  oedema  disappeared  entirely.  The 
recurring  growth  had  reached  the  pleura,  as  was  evident  from  the 
presence  of  pleuritic  effusion,  which  was  aspirated.  A  specimen 
taken  from  the  irradiated  area  showed  colloid  degeneration,  the 
adenoid  character  having  disappeared.  This  seems  to  some  extent 
to  show  the  mode  of  cell-metamorphosis  which  the  cells  undergo 


Fig.  279. — Case  of  Carcinoma  Mammae 
after  First  Operation.  (Compare  Fig. 
278.) 


SPECIAL    INDICATION'S 


403 


Fig.  280. 


-Recurrent  Carcinoma  Mam.m.e. 
(Compare  Fig.  281.) 


after  irradiation.  (Com- 
pare section  on  Pysiolog- 
ical  Effects. ) 

The  patient  was  a1  the 
time  of  presentation  free 
from  pain  and  her  appe- 
tite had  increased.  A  few 
days  later  the  superficial 
layers  around  the  ulcerat- 
ing area  shed  themselves 
as  scabs. 

Even  in  this  desperate 
case  the  temporary  influ- 
ence of  the  rays  was  well 
marked.  The  patient 
after  a  long  period  of 
euphoria     succumbed     to 

pleuropneumonia  three  months  later.  The  author's  observation 
suggests  that  irradiation  should  be  begun  as  soon  as  union  is  per- 
fect after  the  removal  of 
the  neoplasm,  and  should  be 
kept  up  for  a  period  of  sev- 
eral weeks. 

Another  case,  presented 
to  the  American  Thera- 
peutic Society,  is  that  of 
an  unmarried  lady  of 
forty-seven  years  who  no- 
ticed a  small  nodule  in  her 
left  breast  in  June,  1896, 
which  caused  slight  pain. 
In  October  of  the  same 
year  she  consulted  a  re- 
puted clinician,  who 
advised  immediate  amputa- 
tio  mamma.  But  she  pro- 
crastinated until  Decem- 
ber 21,  1897,  when  she 
submitted  to  extensive  operation.  Eecovery  was  speedy,  and  it  was 
not  until  August,  1898,  when  recurrence  took  place  near  the  ster- 


Fig.   281. — Case    illustrated 
Recovering. 


Fig.  280, 


404 


THE    RONTGEN    RAYS 


num.  In  November  of  the  same  year  a  second  extirpation  was  suc- 
cessfully performed.  Another  recurrence  took  place  March,  1900, 
but  no  operation  was  attempted  then,  the  treatment  consisting  espe- 
cially in  local  application  of  antiseptics  and  in  the  administration 
of  Fowler's  solution.  On  March  17th  the  author  saw  the  patient 
for  the  first  time.  Then  there  was  a  large  hard  mass  of  the  size  of 
a  fist,  covering  the  manubrium  sterni  and  a  large  ulcerated  area  in 
the  left  mammary  region  (see  Fig.  280).  Considerable  oedema 
was  also  present.  After  twenty-four  irradiations,  which  on  the 
average  lasted  twenty  minutes  at  each  time,  the  large  mass  above 


Fig.  282. — Fibkocaecinoma  Mammae,  a  year  after  its  onset. 


the  sternum  shrank  almost  entirely  and  much  of  the  ulcerations 
cicatrized.     The  oedema  disappeared  completely  (Fig.  281). 

After  an  interval  of  three  months  slight  recurrence  took  place. 
Irradiation  was  done  again  for  ten  minutes  each  time.  After  the 
seventeenth  seance  dermatitis  set  in,  so  that  the  treatment  was 
stopped.    This  case  is  still  under  observation. 

Fig.  282  illustrates  the  case  of  a  woman  of  forty-five  years  who 
did  not  submit  to  operation  until  a  year  after  the  onset  of  the 
disease.  Recurrence  took  place  four  months  after  thorough  re- 
moval. Partial  extirpation  was  performed  again,  and  frequent 
irradiation  was  done  until  intense  reaction  took  place.     After  the 


SPECIAL    INDICATIONS 


405 


K 


I 


reaction  was  over,  the  patient  improved  considerably.  A  second 
recurrence  look  place  six  months  after  the  partial  extirpation,  to 
which  the  patient  succumbed. 

As  to  further  statistics,  reference  is  made  to  the  author's  pre- 
vious publications,  New  York  Medical  Journal,  May  24,  L902,  Re- 
view of  Eeviews,  August, 
1902,  and  Medical  Record, 
February  14,  1903. 

As  emphasized  above, 
the  Rontgen  rays  should 
not  be  substituted  for  the 
surgical  treatment  of  car- 
cinoma. It  should  not 
even  be  tried,  because  a 
carcinomatous  a  r  e  a  if 
often  irradiated  becomes 
degenerated,  and  when 
operation  is  submitted  to 
then  union  by  first  inten- 
tion is  not  obtained.  Ex- 
cessive haemorrhage  may 
also  occur  in  the  meta- 
morphosed tissues. 

It  should  also  be  kept 
in  mind  that  partial  op- 
erations, which  in  former 
years  were  regarded  un- 
scientific, are  indicated  if 
the  after-treatment  is  car- 
ried on  by  irradiation.  In 
deep-seated  carcinoma  an 
attempt  should  be  made 
to  remove  as  much  as  pos- 
sible of  the  outer  portion 
in    order    to    enable    the 

rays  to  get  better  access  to  the  eleeper-seateel  strata.  For  this  end 
it  is  sometimes  even  advisable  not  to  unite  the  wound  margins,  but 
to  keep  them  open  and  separated,  so  that  the  rays  do  not  need  to 
penetrate  the  overlying  tissues  first,  but  attack  the  diseased  area 
directly. 


Fig. 


J.  —  Recurrence 
Mammae. 


of      Carcinoma 


406 


THE    RONTGEN    RAYS 


Ordinarily  prophylactic  irradiation  should  he  begun  as  soon 
as  union  of  the  wound  is  obtained,  and  continued  until  slight  reac- 
tion shows  itself. 

Fig.  283  illustrates  the  case  of  a  woman  of  twenty-eight  years, 
whose  small  mammary  tumour  was  thought  to  be  an  adenoma, 
whereupon  extirpation  was  performed.  Three  months  thereafter 
recurrence  took   place,   but   no   surgical   steps   were   undertaken. 

When  the  author  saw  the 
case,  the  tumour,  which 
proved  to  be  of  a  carcino- 
matous nature,  had  gone 
beyond  the  possibilities  of 
surgical  technique.  Irra- 
diation was  tried  there- 
fore, which  improved  the 
condition  remarkably.  At 
the  present  writing  there 
is  only  a  small  cancer- 
ous area,  and  the  general 
health  of  the  patient  is 
good. 

Fig.  284  illustrates  an 
inoperable  carcinomatous 
tumour  of  the  infracla- 
vicular region  in  a  woman 
of  seventy  years.  In  cases 
of  this  kind  the  Rontgen- 
ray  treatment  must  at 
least  be  tried  in  a  pallia- 
tive sense. 

Fig.    285    shows    car- 
cinoma of  the  skull  in  a 
woman  of  sixty-eight  years,  which  was  extensively  extirpated  by  the 
author.     Recurrence  took  place  two  years  afterward. 

In  Fig.  286  adenocarcinoma  developing  after  the  removal  of  an 
old  suppurating  sebaceous  cyst  is  recognised.  After  thorough 
extirpation  of  the  growth,  irradiation  was  done  prophylactically. 
No  recurrence  was  observed  two  years  thereafter. 

The  same  observation  was  made  in  a  man  of  forty-five  years, 
whose  large  epithelioma  of  the  lower  lip   (Fig.   287)   was   thor- 


Fig.  284. — Infraclavicular  Carcinoma  in  a 
Woman  of  Seventy  Years. 


SPECIAL    INDICATIONS 


407 


oughly  removed  a  year  after 
its  onset,  the  patient  having 
treated  himself  by  ointments. 
Irradiation  was  taken  up  at 
once,  recurrence  having  been 
observed. 

In  the  case  of  a  lady  of 
sixty  -  seven  years,  suffering 
from  carcinoma  of  the  vaginal 
introitus  (Fig.  288),  the  same- 
good  result  was  observed  after 
the  combined  treatment — viz.. 
extirpation  followed  by  irra- 
diation. 

SARCOMA 

It  was  the  privilege  of  the 
author  to  show  the  first  case 
of  sarcoma  successfully  treated 
by  the  Eontgen  method.     In  view  of  the  good  results  obtained  in 


Fig.  285. — Carcinoma  of  Skull. 


Fig.    286. — Cahcinoma    Developing 
from  an  old  sebaceous  cyst. 


Fig.    287.- 


-Epithelioma   of   Lower 
Lip. 


408 


THE    BONTGEN    KAYS 


the  treatment  of  carcinoma,  it  was  obvious  to  think  of  giving  the 
rays  a  trial  in  sarcoma.  The  first  patient,  presented  to  the  Ger- 
man Medical  Society  of 
New  York  City  on  May 
6,  1901  (Muenchener 
medicinische  Wochen- 
schrift,  No.  32),  suf- 
fered from  melanosar- 
coma.  He  was  a  strongly 
built  cooper  of  thirty-six 
years.  He  remembered 
that  for  fifteen  years  he 
h  a  d  observed  a  small 
black  speck  (mole?)  at 
the  region  of  his  external 
malleolus.  About  one 
year  ago  it  assumed  the 
appearance  of  a  common 
verruca.  A  continuous 
increase  of  size  was  ob- 
served then.  In  November,  1900,  the  "verruca"  became  sensitive 
and  the  surface  began  to  excoriate.  Carbolic-acid  baths  were  now 
prescribed  by  the  patient  himself,  and  faithfully  used,  until,  about 


Fig.    288. — Carcinoma    of   Vaginal    Introitus 
in  a  Woman  of  Sixty-seven  Years. 


Fig.  289.— Melanosarcoma. 


Christmas,  the  growth  had  reached  the  size  of  an  apple.     It  was 
not  until  then  that  the  patient  became  afraid  and  consulted  his 


SPECIAL    INDICATIONS 


109 


Fig.  290! — Specimen  of  Case  of  Melano- 
sarcoma  illustrated  by  flq.  289. 


family  physician,  who  referred  him  to  the  author's  department  at 

St.  Mark's  Hospital. 

On  December  24,  1900,  the  author  found  the  following  state 

present:  The  strongly  built  patient  shows  a  healthy  appearance. 

He  a  <1  in  i  t  s  being  a  free 
drinker.  The  family  history 
is  good.  At  the  region  of 
his  left  externa]  malleolus  a 
tumour  of  the  size  of  an  ap- 
ple is  noticeable  (Fig.  289). 
Its  consistence  is  moderately 
hard,  its  surface  of  a  smoky 
gray  colour,  and  it  seems  to 
have  originated  from  the 
continence  of  small  warts.  It 
cannot  be  dislodged  from  its 
base.  The  inguinal  region 
contains  a  gland  of  the  size 
of  a  walnut. 

At  first   the  diagnosis   of 

lymphosarcoma  was  made,  and  amputation  considered  accordingly. 

but  the  patient  refused  to  submit  to  it.     His  family  also  being 

adverse  to  such  a  radical  step, 

the    author    contented    himself 

with  extirpation  of  the  tumour 

and  of  the  inguinal  gland.     The 

apparently   healthy    periosteum 

of  the  externa]    malleolus   was 

removed,  together  with  the  neo- 
plasm.    Eecovery  being  perfect 

in  a  week  the  patient  left  the 

hospital. 

Microscopical  examination  of 

the  growth  revealed  the  presence 

of  pigment,  which  proved  that 

we  had  to  deal  with  melanosar- 

coma,  the  most  malignant  type 

of  sarcoma  (Figs.  290  and  291 ) . 

The  patient  returned  to  the  hospital  six  weeks  afterward.     The 

same  tumour  showed  at  the  outer  malleolus  again,  but  it  was  some- 


FiG.  291. — Melanosarcoma.     (Compare 
Figs.  289  and  290.) 


410 


THE    KOXTGEN    KAYS 


Fig.  292. — Appearance  after  Seventh 
Irradiation.  (Compare  Pigs.  289, 
290  and  291.) 


what  broader  and  flattened.     Its  margin  was  encircled  by  a  few 

bluish-black  nodules,  of  the  size  of  a  pea,  which  could  be  compared 

to  hemorrhoidal  nodules.  A 
glandular  convolution  of  the 
size  of  a  goose's  egg  had  de- 
veloped in  the  inguinal  region 
in  the  meantime.  Extirpation 
was  performed  again.  The  pa- 
tient withdrew  from  treatment 
two  weeks  afterward,  his  ex- 
cuse being  that  he  felt  per- 
fectly well  again.  Four  weeks 
thereafter  he  presented  him- 
self again  with  a  relapse.  This 
time  there  were  about  thirty 
dark  bluish-black  grape-like 
nodules  of  various  size.     The 

largest  nodules  bled  easily  on  touch.     The  inguinal  region  showed 

a  tumour  of  the  size  of  the  head  of  a  new-born  child.     On  the 

inner  surface  of  the  leg,  especially  alongside  the  inner  border-line 

of    the    calf,    several    dozens 

of    nodules    had    originated, 

which  resembled  those  of  the 

tumour  itself  closely.     Their 

size   varied   between   that    of 

the  head  of  a  pin  and  that  of 

a    cheny.      Extirpation    was 

done  once  more.  The  micro- 
scopical  examination   of   the 

removed    portion,    made    by 

Dr.     H.     Kreuder,     showed 

well-developed  large  sarcoma 

cells.      The  pigment  is  chiefly 

seen  in  the  form  of  streaks, 

but  by  higher  magnification 

it  can  be  recognised  as  fine 

granules  which  are  contained 

in    cells    in    the    connective- 

,  •  n  ,        j,     ,,  Fig.     293.  —  Osteosarcoma     of     Orbit 

tissue    framework    of    the  bhowisq     Nhobotw      Rontgen.Rat 

tumour.    In  some  places  they  Burn. 


SPECIAL    INDICATIONS 


411 


resemble  a  netting.  Few  cells  in  the  alveoli  of  the  sarcoma  cells 
are  pigmented.  But  some  portions  of  the  section,  especially  the 
necrotic  areas,  show  a  great  amount  of  pigment.  One  of  the  speci- 
mens was  coloured  with  hematoxylin  and  eosine,  and  a  second  with 

Van  Gieson's  fluid. 

The  patient  would  now  have  submitted  to  amputation,  but  con- 
sidering metastasis,  the  prospects  of  such  operation  at  this 
late  stage  would  not  have  appeared  promising.  Serum  treatment 
was  now  considered  first.  Although  the  author  himself  so  far  did 
not  experience  much  benefit  in 
a  fairly  large  number  of  his 
malignant  cases,  he  still  re- 
gards its  use  indicated  in  such 
desperate  cases.  But  at  the 
same  time  the  thought  of  Ront- 
gotherapy  suggested  itself. 

Without  entertaining  au- 
dacious hopes  irradiation  of 
the  defect  left  after  the  last 
extirpation  was  begun.  The 
time  of  exposure  was  at  first 
ten,  then  twenty  and  thirty, 
with  moderate  light,  and  at 
last  once  even  forty-five  min- 
utes. While  the  exposure 
lasted  forty-five  minutes  the 
patient  felt  an  itching  sensa- 
tion over  the  whole  leg,  which 
lasted  for  several  hours  after 
the  seance.    Up  to  the  time  of 

presentation  irradiation  had  been  done  seven  times.  After  six 
weeks  there  was  not  only  no  trace  of  relapse,  but  a  number  of  the 
metastatic  nodules  of  the  calf,  especially  those  near  the  area  of 
irradiation  disappeared,  while  others  have  shrunk  (Fig.  292). 

The  inguinal  tumour  became  larger  during  the  time  of  this 
treatment. 

Three  weeks  after  the  demonstration  the  defect  at  the 
outer  aspect  of  the  malleolus  had  cicatrized  perfectly.  After 
three  months  no  recurrence  had  been  observed.  The  inguinal 
tumour  was  removed  on  the  day  after  the  demonstration  as  in- 


flg.    294.— osteosarcoma   illustrated 
by  Fig.  293,  one  teak  later. 


412 


THE    ROKTGEN    RAYS 


tended,  and  now  the  inguinal  area  was  also  irradiated  every  sec- 
ond day  for  ten  minutes.     Two  weeks  after  the  removal  a  derma- 


Fig.  295.— Skiagraph  of  Case  illustrated  by  Figs.  293  and  294. 


titis  set  in,  which  prevented  further  irradiation.     The  patient  suc- 
cumbed  suddenly  to   metastasis   of  the   lungs.      The   disease   had 


SPECIAL    INDICATIONS 


413 


reached  a  stage  in  which  final  recovery  could  hardly  be  expected, 
and  it  is  to  be  regretted  thai  the  thought  of  the  Rontgotherapy 

did  not  suggest  itself  to  the  author  at  an  earlier  stage,  as  treat- 
ment might  then  have  effected  a  local  cure  before  metastasis  could 
have  taken  place.  But  the  course  proved  the  efficiency  of  the  rays, 
because  the  fact  cannot  be  denied  that,  in  great  contrasi  to  the 
former  course,  after  the  preceding  extirpation  no  relapse  was 
observed.  The  fact  that  well-developed  sarcomatous  tissue  shrank 
and  cicatrized  is  also  beyond 
doubt. 

Similar  experience  was  gained 
in  the  case  of  a  lady  of  forty-two 
years,  who  showed  the  signs  of  sar- 
coma of  the  orbit  in  the  fall  of 
1901.  Enucleation  of  the  eyeball 
had  to  be  undertaken,  but  recur- 
rence in  the  frontal  bone  took 
place  three  months  thereafter,  and 
reached  such  an  extent  that  it  was 
regarded  inoperable. 

After  having  ascertained  the 
extent  of  the  growth  by  a  skia- 
graph the  author  removed  the  dis- 
eased bone  portions.  Three  weeks 
thereafter,  when   cicatrization  had 

taken  place,  irradiation  was  begun  three  times  a  week,  exposing  ten 
minutes  each  time.  No  change  during  two  months'  treatment  was 
observed.  But  when  irradiation  was  stopped  for  three  weeks,  the 
signs  of  recurrence  showed  up  again,  the  vicinity  of  the  orbit  pro- 
jecting far.  Now  irradiation  was  resorted  to  every  day  at  small  dis- 
tance, low  vacuum  and  high  current  being  chosen.  After  eleven 
exposures  extensive  dermatitis  developed,  which  proved  to  be  of 
ulcerative  type,  within  the  centre  of  the  irradiated  area.  At  the 
same  time  complete  alopecia  at  the  diseased  side  set  in  (Fig.  293). 
The  patient  suffered  considerably  for  a  week,  then  the  symptoms 
gradually  subsided.  The  treatment  consisted  in  the  application  of 
Burow's  solution  at  first,  and  in  the  use  of  xeroform  gauze  later. 
Three  weeks  after  the  beginning  of  the  vehement  dermatitis  all 
signs  of  the  sarcomatous  infiltration  had  disappeared,  especially 
the  projection,  and  the  general  condition  of  the  patient  improved 


Fig.  296.— Glioma. 


414 


THE    EOXTGEN    KAYS 


remarkably.     There  is,  in  fact,  no  abnormality  noted  at  present. 
This  state  of  euphoria  has  continued  up  to  the  present  time. 

Fig.  294  shows  the  normal  condition  of  the  patient  a  year 
afterward.     The  skiagraph  indicates  the  removed  bone  portions 

(Fig.  295).  Alopecia  is 
still  well  marked  (Dem- 
onstrated to  the  Surgical 
Section  of  the  New  York 
Academy  of  Medicine, 
March  meeting,  1903). 
Whether  it  will  continue 
indefinitely  is  at  least 
doubtful ;  nevertheless,  the 
entire  disappearance  of 
the  recurrent  growth  is 
to  be  regarded  as  a  most 
important  fact.  (At  the 
present  writing  the  pa- 
tient still  enjoys  perfect 
health.) 

Fig.  296  represents  a 
counterpart  to  this  case. 
It  illustrates  a  glioma, 
which  necessitated  enucle- 
ation of  the  eyeball  in  a 
girl  of  two  years.  Even 
in  this  desperate  case 
great  temporary  improvement  at  a  late  stage  was  observed. 

Fig.  297  illustrates  osteosarcoma  of  the  skull  in  a  man  of 
sixty-six  years.  A  skiagraph  obtained  then  showed  arrosion  of 
the  frontal  bone.  Extensive  extirpation  was  performed  by  the 
author  at  St.  Mark's  Hospital.  Microscopical  examination  proved 
it  to  be  a  round-cell  sarcoma  of  the  ordinary  type  (Fig.  298). 
After  removal  there  was  an  immense  defect  which  was  filled  by 
flaps  taken  from  the  vicinity.  The  process  of  cicatrization  occu- 
pied two  months.  Then  irradiation  was  done  for  a  month  at  inter- 
vals of  three  days.  The  patient  did  very  well  for  two  years.  Then 
a  small  nodule  showed  in  one  of  the  scars  which  had  formed  by 
cicatrization.  After  a  few  weeks  a  second  one  formed  (Fig.  299). 
It  was  only  then  that  the  patient  presented  himself  again  to  the 


Pig.  297.— Osteosarcoma  of  Skull. 
(Compare  Pigs.  299  and  300.) 


SPECIAL    INDICATIONS 


415 


author.  Irradiation  was  taker  up  ai  once,  the  intervals  being 
short  and  the  exposures  long.  After  three  weeks  intense  reaction 
set  in,  blisters  forming  within  the  area  of  cicatrization.  At  firsl 
warm  Burow's  solution  was  applied,  a  few  days  later  xeroform 
gauze  was  used.  Two  weeks  after  the  reaction  had  set  in,  the  two 
large  nodules  had  completely  disappeared  (Fig.  300).  Four  days 
after  the  onset  of  the  dermatitis  a  piece  was  exsected  from  one  of 
the  irradiated  nodules. 

According  to  the  laboratory  report  made  by  the  courtesy  of  Dr. 
Henry  Kreuder,  this  specimen  showed  the  following  changes:  An 
abundance  of  fibrous  connective  tissue,  which  appears  very  dense 
and  wavy,  showing  exceptionally  few  nuclei  and  being  almost  struc- 
tureless. On  first  sight  the  sarcoma  cells  are  scattered  through- 
out this  new   connective   tissue,   and   only   in   some  places   small 


Fig.  298.— Round  Cell  Sarcoma. 


areas  of  sarcoma  cells  can  he  encountered.  Fig.  301  shows  dense 
connective  tissue  with  sarcoma  cells  scattered  through  it,  also  an 
area  of  myxomatous  tissue  changing  into  dense  connective  tissue. 

Upon   closer   study   one   notices  that    on   the   surface    of   the 
tumour  (epithelium  wanting,  Fig.   302)   a  very  marked  necrosis 


416 


THE    RONTGEN    EAYS 


and  an  inflammatory  process  are  going  on,  which  does  not  take 
place  only  in  the  sarcomatous,  but  also  in  the  newly  formed  dense 
connective  tissue.     This  necrosis  and  inflammation  are  probably 

the  result  of  the  irradiation, 
which  is  so  powerful  as  to 
cause  a  complete  disintegra- 
tion of  the  superficial  tissue. 
The  deeper  parts  of  the 
specimen  (Fig.  303)  do  not 
show  any  areas  of  necrosis, 
but  the  formation  of  a  great 
deal  of  myxomatous  tissue 
everywhere  in  the  growth, 
and  this  seems  to  be  the 
origin  of  the  dense  fibrous 
connective  tissue  which  is  so 
a  b  u  n  (1  a  n  t  throughout  the 
specimen.  Fig.  301  shows 
this  quite  distinct.  Besides 
the  changes  above  one  notices 
that  the  walls  of  the  small 
blood-vessels  have  become 
thickened  on  account  of  the 
formation  of  connective  tis- 
sue in  the  i  n  t  i  m  a  and 
The  change   in  the  vessel  walls   are   not   shown   in   the 


Fig.     299. — Case    illustrated    by    Fig 
297,  two  years  after  extirpation. 


media, 
photographs. 

The  specimens  were  prepared  by  being  fixed  in  a  mixture  of 
Midler's  fluid  and  formalin,  hardened  in  alcohol,  and  embedded  in 
clove-oil  celloidin. 

The  staining  was  done  with  alum-hasmatoxylin  and  eosin  and 
picric-acid  fuchsin  and  thionin. 

Figs.  304-314  show  various  kinds  of  sarcoma  treated  after  the 
same  principles,  all  of  them  being  operated.  In  most  of  them 
recurrence  took  place. 

Fig.  304  shows  round-celled  sarcoma,  originating  from  the 
superior  maxilla,  in  a  child  of  six  months.  Moderate  irradiation 
of  the  operated  area  (Fig.  305)  was  begun  a  week  after  operation. 
Eecurrence  took  place  two  months  after  extirpation.  The  patient 
died  from  metastasis. 


SPKCIAL    INDICATION'S 


417 


Fig.  306  illustrates  osteosarcoma  of  superior  maxilla  (spindle- 
celled)  in  a  man  of  thirty-six  years.  Moderate  irradiation  was 
begun  three  weeks  after  operation.  Recurrence  took  place  nine 
months  after  the  operation.     The  patient  died  from  metastasis. 

Fig.  307  shows  a  spindle-celled  osteosarcoma,  originating  from 
the  inferior  maxilla,  in  a  woman  of  sixty-two  years.  Moderate 
irradiation  was  begun  two  weeks  after  operation.  Recurrence  took 
place  four  months  afterward,  death  being  due  to  the  erosion  of  the 
external  carotid  artery. 

Figs.  308-313  illustrate  eases  in  which  no  recurrence  has  taken 
place  up  to  the  present  time,  in  all  of  them  powerful  irradia- 
tion having  been  employed.  In  all  cases  intense  reaction  took 
place. 

Fig.  308  shows  the  round-celled  sarcoma  of  a  man  of  seventy 
years,  which  originated  from  the  periosteum  of  the  sternum  and 
the  second  rib.  A  large  de- 
fect remained  after  extirpa- 
tion, which  was  partially 
covered  by  a  plastic  opera- 
tion. 

Fig.  309  illustrates  the 
spindle  -  celled  fibrosarcoma 
in  the  mamma  of  a  woman 
of  twenty-three  years.  Ex- 
tensive removal  was  under- 
taken. 

Fig.  310  shows  round- 
celled  sarcoma  in  the  groin  of 
a  man  of  forty  years.  The 
operation  was  done  in  the 
same  way  as  in  the  case  illus- 
trated by  Fig.  289. 

Fig.  311  indicates  round- 
celled  periosteal  sarcoma, 
originating  from  the  condy- 
lus  femoris  externus,  in  a 
man  of  thirty-three  years. 
Amputation  being  refused, 
extirpation  was  undertaken.     Irradiation  was  begun  seven  days 

after  operation. 
28 


Fig.  300.  —  Recurrent  Sarcoma  of 
Skull,  Treated  ,bt  Irradiation. 
(Compare  Figs  297  and  299.) 


' 


Fig.  301. — Sarcomatous  Tissue  after  Irradiation. 


Fig.  302.— Sarcomatous  Tissue  after  Ikradiation  (epithelium  wanting). 
418 


SPECIAL    INDICATIONS  419 

Fig.  312  shows  a  ease  of  the  same  nature  in  a  man  of  sixty-four 
years. 

Fig.  313  illustrates  a  round-celled  sarcoma  in  the  Leg  of  a 
woman  of  fifty  years. 

Even  in  the  deplorable  rase  of  a  man  of  twenty-eight  years. 
illustrated  by  Fig.  314,  temporary  improvement  was  obtained,  the 
extensive  oedema  disappearing  as  soon  as  the  ulcerated  area  cica- 

,.  'i 


-    fc  •••tfc i  v,  <* 


*  ^     * 


Fig.  303. -Sarcomatous  Tissue,  Deep  Stratum,  after  Irradiation. 

trized.  The  patient  had  previously  submitted  to  extirpation,  and 
succumbed  four  months  afterward  to  the  recurrence. 

The  statements  of  the  author  were  corroborated  later  by  the 
observation  of  Williams,  Pusey,  Coley,  Morton,  Allen,  Skinner,  and 
others.  Even  in  deep-seated  tumours  an  inhibitory  action  could  be 
noticed. 

The  superficially  located  growths,  of  course,  yield  most  readily 
to  the  Rontgen-ray  therapy.  Next  to  it  tumours  primary  in  the 
lymph-glands  may  be  considered. 

The  observations  of  William  P.  Coley  (Medical  Record,  March 
21,  1903),  to  whom  science  is  greatly  indebted  for  his  indefatiga- 
ble  investigations  in  this  important  field,   are  noteworthy.     He 


V 


420 


THE    KONTGEN    RAYS 


treated  24  cases  of  the  vari- 
ous types  of  sarcoma,  among 
them  were  17  round-celled, 
3  spindle-celled,  and  1  me- 
lanotic round-celled. 

In  4  the  variety  was 
doubtful.  Of  the  3  cases  of 
spindle-celled  sarcoma,  one, 
recurrent  sarcoma  of  the  su- 
perior maxilla,  showed  no 
improvement.  A  recurrent 
sarcoma  of  the  chest  wall,  as 
well  as  a  spindle-celled  sar- 
coma of  the  chest,  was  still 
under  treatment,  with  slight 
improvement.  Another  case, 
formerly  under  Coley's  care, 
a  spindle-celled  sarcoma  of 
the  abdominal  wall  and  pel- 
vis, the  size  of  an  eight 
months'  pregnant  uterus,  was 
treated  for  seven  months 
by  Skinner,  with  general  improvement,  but  slight  local  diminution. 
Of  the  17  cases  of  round-celled  sarcoma,  all  inoperable,  four 
have  disappeared  entirely,  yet 
in  every  case  a  recurrence  has 
taken  place  in  less  than  a  year. 
In  all  of  these  cases  the  Rontgen- 
ray  applications  were  made  four 
times  a  week,  and  continued 
over  a  period  of  many  months. 
Among  these  Avas  a  very 
extensive  recurrent  round-celled 
sarcoma  of  the  neck,  both 
sides,  superior  and  infraclavic- 
ular, pectoral,  and  axillary  re- 
gions on  one  side  and  medias- 
tinal glands.  (The  early  his- 
tory of  this  case  is  given  in  FlG-  305—Case  of  Osteosarcoma  of 
„     '    .       .,       _-  j.  „    ,..  Superior   Maxilla,  illustrated 

lull  m  the  Transactions  of  the  BT  FlG>  304j  AFTER  REM0VAL. 


Fig.  304. — Osteosarcoma  Originating 
from  Superior  Maxilla.  (Compare 
Fig.  305.) 


Fig.   306.— Osteosarcoma   of  Superior 
Maxilla. 


Fig.    307. — Osteosarcoma    Originating 
from  Inferior  Maxilla. 


Fig.  308. — Sarcoma  Originating  from 
the  Periosteum  of  the  Sternum  and 
the  Second  Rib. 


Fig.   309. — Fibrosarcoma  Mammae  in   a 
Woman  of  Twenty-three  Years. 


421 


422 


THE    RONTGEN    RAYS 


Fig.  310. 


-Sarcoma  of  Gkoin  in  a  Man 
of  Forty  Years. 


American  Surgical  Association,  1902.)  The  patient,  aged  forty- 
five  years,  was  confined  to  bed  and  in  such  a  hopeless  condi- 
tion that  she  was  not  expected  to  live  more  than  two  months. 

The  toxine  treatment  had  been 
used  and  abandoned.  On  Feb- 
ruary 10th  Coley  began  the 
Rontgen-ray  treatment  purely 
as  an  experiment.  The  im- 
provement was  more  striking 
and  rapid  than  in  any  other 
case  that  he  had  observed. 
The  tumours  steadily  disap- 
peared, and  by  July  1  there 
remained  only  a  small  nodule 
the  size  of  an  almond  anterior 
to  the  sternomastoid  muscle. 
This  he  removed  under  ether 
purely  for  pathological  study, 
and  the  examination  by  Dr. 
George  Biggs  confirmed  the  original  diagnosis.  The  patient  had 
regained  her  normal  strength,  and  went  to  the  country  for  the  sum- 
mer. She  returned  on  September  24th  with  a  local  recurrence  the 
size  of  an  English  walnut  in  front  of  the  ear  in  the  lower  portion 
of  the  parotid.  Both  groins 
were  filled  with  multiple  tu- 
mours, varying  in  size  from 
a  hen's  egg  to  a  pigeon's 
egg.  In  addition,  there  was 
an  intra  -  abdominal  tumour 
smooth,  globular,  fairly  mova- 
ble, apparently  originating  in 
the  ascending  colon  or  its 
mesentery.  There  was  un- 
doubted constriction  of  bowel 
at  this  point.  Her  condition  again  seemed  hopeless,  but  Coley 
resumed  the  Rontgen-ray  treatment,  and  in  three  weeks  the 
nodule  in  the  parotid  region  had  entirely  disappeared.  At 
present  the  groin  tumours  have  entirely  disappeared,  and  the 
tumour  in  the  abdomen  has  decreased  about  one-half.  Janu- 
ary 19,  1903,  the  abdominal  tumour  is  steadily  decreasing,  and 


Fig.   311.— Periosteal  Sarcoma  of  Ex- 
ternal Condyle. 


SPECIAL    INDICATIONS 


423 


Pig.  312. — Sarcoma  of  Leg  Show 
ing  Gangrene  in  its  Centre. 


the    patient's    genera]    health    is 
good. 

( loley's  experience  showed  that 
in  several  c  a ses  of  inoperable 
round-celled  sarcoma  in  which  his 
toxine-treatment  had  been  tried 
and  Tailed,  the  Rontgen-ray  caused 
entire  disappearance  of  the  tu- 
mours. Yet  all  of  these  cases  are 
of  recent  dale,  and  in  all  there 
has  been  a  speedy  recurrence. 

In    a    larger    number    of    his 
cases   of  inoperable  sarcoma,   the 
tumours  disappeared  entirely  un- 
der the  toxines,  and  remained  well 
from  three  to  ten  years  after  treat- 
ment.    In  all  he  had  20  patients 
with    inoperable    sarcoma    remain    well    from    two    to    ten    years 
after  the  disappearance  of  the  tumour  under  the  mixed  toxine 
treatment.      Of  these,  15  patients  were  well  from  five  to  ten  years. 

In  observing  the  effect  of  the  Ront- 
gen  ray  upon  3  cases  of  spindle-celled 
sarcoma,  it  was  found  to  be  exceedingly 
slight.  Yet  just  in  this  class  of  cases — 
the  spindle-celled — the  result  of  the  tox- 
ine treatment  has  been  by  far  the  most 
satisfactory,  nearly  50  per  cent  of  the 
cases  of  inoperable,  spindle-celled  sar- 
coma having  disappeared  under  the 
treatment  in  his  own  experience.  In  the 
round-celled  variety,  however,  upon 
which  the  influence  of  the  toxines  is 
much  less  pronounced,  the  immediate 
results  from  the  Rontgen-ray  treatment 
seem  to  have  been  best.  In  a  very 
large  inoperable  round-celled  sarcoma 
two-thirds  of  the  growth  had  disap- 
peared under  the  toxine  treatment,  and 

at  this  point  the  Rontgen-ray  was  used  in       „      „,„      ^ 

1  fa  Fig.  313.  —  Proliferating 

addition  to  the  toxines  with  the  result  Sarcoma  of  Leg. 


424 


THE    RONTGEN    RAYS 


Fig.  314. — Periosteal  Sarcoma  of  Leg. 


that  the  entire  tumour  disap- 
peared three  months  later. 

Coley  concludes,  there- 
fore, that  in  deep-seated  and 
inaccessible  growths  the  re- 
sults from  the  toxines  will 
probably  prove  better  than 
from  the  Rontgen-rays. 

The  author  agrees  with 
Coley  that  there  is  no  objec- 
tion to  using  both  methods 
of  treatment  at  the  same 
time,  and  that  there  is  reason 
to  believe  that  the  combined 
treatment  will  give  better  re- 
sults than  either  used  alone. 
There  are  a  larger  number  of 
cases  of  inoperable  sarcoma 
treated  either  with  the  Ront- 
gen-ray  or  the  toxines,  in  which  inhibitory  action  is  almost,  but 
not  quite,  sufficient  to  check  the  growth,  and  it  seems  but  reason- 
able to  suppose  that  the  com- 
bined action  of  the  Rontgen- 
rays  and  toxines  might  be  suf- 
ficient not  only  to  check  the 
growth,  but  to  cause  it  to  dis- 
appear. 

The  principles  as  well  as 
the  technique  of  this  treatment 
are  the  same  as  described  for 
carcinoma  ( see  foregoing 
sections).  Just  as  in  carcino- 
ma, irradiation  should  not  be 
substituted  for  operative  treat- 
ment in  operable  tumours, 
and  prophylactic  irradiation 
should  be  begun  as  soon  as 
union  of  the  wound  is  obtained. 

It  must  also  be  continued  un- 

.......  ,.  ,  . ,     n„        Fig.    315.— Osteosarcoma    of   Frontal 

til  slight  reaction  shows  itself.  BoNE  AND  orbits 


SPECIAL    INDICATIONS  125 

But  in  inoperable  growths,  like  the  ease  of  a  boj  of  eighteen 
years,  illustrated  by  Fig.  315,  the  Rontgen  rays  are  the  therapy  par 
excellence.  The  large  extent  of  the  round-celled  sarcomatosis  is 
indicated  by  skiagraphic  examination. 


HODGKIN'S    DISEASE    (PSEUDOLEUKEMIA) 

Hodgkin's  disease  bears  a  strong  resemblance  to  sarcoma.  Of 
the  astiology  and  essential  pathology  of  this  obscure  affection  very 
little  is  known  yet.  Its  characteristics  are  an  enlargement  of  the 
lymphatic  glands,  lymphatic  tissues  forming  in  internal  organs 
like  the  lungs,  the  liver,  kidneys,  spleen,  and  intestines.  As  a  rule 
the  swelling  begins  in  the  glands  of  the  neck,  one  side  of  which 
is  soon  filled  up  by  a  mass  of  glands.  Probably  the  nature  of 
Hodgkin's  disease  is  infection,  the  specific  effect  of  the  alleged 
bacterium  being  caused  by  its  predilection  for  lymphoid  tissues. 
No  permanent  therapeutic  results  have  been  obtained  so  far,  ex- 
tirpation as  well  as  administration  of  arsenic,  bone-marrow,  and 
toxine  treatment  having  given  only  temporary  benefit. 

Irradiation  tried  recently  has  given  much  more  satisfactory 
results.  N.  Senn  (New  York  Medical  Journal,  April  18,  1903) 
reported  two  cases,  in  which  a  perfect  cure  was  effected.  One  of 
the  cases  was  that  of  a  farmer  of  forty-five  years  whose  glandular 
affections  dated  back  a  year.  It  had  commenced  in  the  cervical 
region  almost  simultaneously  on  both  sides,  and  involved  very  ex- 
tensively the  glands  of  these  localities  as  well  as  the  axillary  and 
inguinal  region.  As  Senn  stated,  there  was  a  macular  eruption  of 
the  skin  all  over  the  chest,  back,  and  abdomen.  The  increased 
respiratory  movements  and  dulness  over  the  anterior  mediastinum 
indicated  the  extension  of  the  disease  to  the  bronchial  and  medias- 
tinal glands.  Spleen  considerably  enlarged.  Liver  dulness 
slightly  increased.  No  tenderness  over  the  junction  of  the  gladi- 
olus with  the  ensiform  cartilage  of  the  sternum  or  epiphyses  of  the 
long  bones.  He  was  anasmic,  but  not  emaciated.  The  blood  ex- 
amination showed  ansemia,  but  no  abnormal  blood-cells.  At  the 
examination,  made  at  11  a.  m.,  the  pulse  was  78,  respiration  22, 
and  temperature  99°  F.  Senn  prescribed  arsenic  and  iron,  and, 
in  view  of  the  heretofore  hopelessness  in  such  case,  advised  in 
addition  the  use  of  the  Rontgen  ray.     The  Rontgen  therapy  was 


426  THE    RONTGEN    RAYS 

referred  to  Dr.  W.  F.  Buttermann,  in  charge  of  this  department 
at  the  St.  Joseph's  Hospital.  As  this  was  the  first  case  of  pseudo- 
leucaemia  in  the  institution  to  be  subjected  to  the  Rontgen-ray 
treatment,  Dr.  Buttermann  took  the  precaution  to  inform  the  pa- 
tient that  in  all  probability  the  treatment  would  result  in  more  or 
less  severe  burns,  owing  to  the  fact  that  glands  in  the  chest  would 
make  it  necessary  to  resort  to  somewhat  vigorous  use  of  the  rays. 
Patient  received  34  treatments  as  follows:  Right  side  of  neck  one 
minute,  left  side  of  neck  one  minute,  neck  from  before  backward 
one  minute,  each  axilla  one  minute,  neck  from  behind  forward  one 
minute,  each  groin  one  minute,  spleen  one  minute.  Daily  sitting 
for  the  first  ten  clays ;  60  volts  8  amperes  were  used  each  day ; 
distance  of  tube  from  surface  12  inches,  a  medium  vacuum  tube 
being  used.  The  treatment  ■  was  commenced  on  March  29,  1902. 
On  April  7th,  after  ten  treatments  had  been  given,  the  glands 
had  undergone  a  noticeable  reduction  in  size.  At  this  time  the 
patient  made  complaint  of  an  intense  itching  all  over  the  chest 
and  a  uniform  redness  made  its  appearance  over  the  chest 
and  axillary  regions.  The  voltage  and  amperage  were  reduced 
to  42  and  6  respectively.  After  the  next  six  treatments  the  volt- 
age was  again  reduced  to  28,  amperage  remaining  the  same.  April 
15th:  The  itching  became  so  severe  that  it  kept  the  patient  awake 
all  night.  The  skin  of  the  chest  blistered.  The  skin  of  the  neck, 
naturally  very  dark,  turned  dark  brown.  A  5-per-cent  boric-acid- 
vaseline  ointment,  applied  twice  a  clay,  relieved  the  itching. 

From  April  16th  to  23d  the  exposures  were  limited  to  the  neck, 
back,  and  groins,  as  the  chest  and  axilla?  were  the  seat  of  quite  an 
extensive  burn.  April  24th :  All  of  the  glands  subjected  to  the 
Rontgen-ray  treatment  have  nearly  disappeared.  The  face  and 
part  of  scalp  exposed  to  action  of  the  Rontgen-ray  are  devoid  of 
hair.  Axillary  and  pubic  hair  has  also  disappeared.  Skin  of  neck 
dark  brown  and  blistered.  The  skin  of  the  chest  from  the  neck 
down  to  about  4  inches  below  the  nipples  exfoliated  in  several 
places.  The  nipples  were  very  sore,  discharging  pus.  The  treatment 
was  suspended,  and  the  patient  discharged  from  the  hospital  with 
instructions  to  continue  the  use  of  the  salve  and  internal  medicine. 
Two  weeks  later  he  returned  to  the  hospital  for  more  medicine, 
and  expressed  himself  as  feeling  well.  His  appetite  was  good,  and 
he  was  able  to  attend  to  his  duties.  N"o  enlarged  glands  could  be 
discovered.     No  elevation  of  temperature.     Breathing  much  im- 


SPECIAL    INDICATIONS  427 

proved.  The  dermatitis  had  improved,  lie  returned  a  second  time 
on  August  1st,  as  he  had  recently  noticed  a  slight  enlargement 
of  the  cervical  and  axillary  glands.  He  is  feeling  well,  and  is  ahle 
to  attend  to  all  of  his  business.  Dermatitis  has  disappeared.  Re- 
turn of  hair  growth.  Patient  received  daily  ten  treatments,  28 
volts  6  amperes;  each  group  of  glands  was  exposed  for  two  min- 
utes at  a  distance  of  12  inches;  tube  the  same  as  before.  The 
glands  disappeared  promptly.  No  return  lias  taken  place  since, 
the  patient  being  in  perfect  health,  with  the  exception  of  a  joint 
affection,  which  has  no  connection  whatever  with  the  pseudoleu- 
csemic  process. 

Senn  maintains  that  there  could  be  but  very  little  doubt  that 
the  constitutional  disturbances  which  followed  the  prolonged  use 
of  the  Rontgen-ray  in  his  second  case,  and  which  set  in  simul- 
taneously with  the  progressive  diminution  in  the  size  of  the  glands, 
were  due  to  a  toxaemia  caused  by  the  absorption  of  the  products  of 
degeneration  of  the  pseudoleueaemic  product.  This  toxic  condition 
unquestionably  was  likewise  the  cause  of  the  increased  enlarge- 
ment of  the  spleen  noted  after  the  second  series  of  applications. 
This  patient  has  been  heard  from  very  recently,  and  it  is  be- 
lieved that  there  are  no  indications  of  the  return  of  the  disease, 
and  he  is  considered  in  perfect  health. 

The  eminent  success  attained  in  these  two  cases  by  the  use  of 
the  Rontgen  ray  can  leave  no  further  doubt  of  the  powerful  influ- 
ence of  the  Rontgen  therapy  in  the  treatment  of  Hodgkin's  disease. 
Williams  also  reported  3  cases,  which  improved  greatly  under  irra- 
diation, only  recently. 


RHEUMATISM 

Sokolow  (Wratsch,  1897,  No.  46)  reported  4  cases  of  acute 
rheumatism  in  children  with  astonishing  results.  The  patients, 
after  being  protected  with  woollen  clothes,  were  irradiated  for  ten 
to  twenty  minutes.  In  one  of  the  patients,  a  girl  of  nine  years,  the 
pain  and  swelling  in  the  wrists,  fingers,  and  knees  disappeared 
after  the  second  seance.  The  distance  of  the  tube  amounted  to  15 
inches.  After  each  irradiation  the  mobility  of  the  joints  was 
increased. 


428 


THE  EOXTGEN  RAYS 


TUBERCULOSIS 

Southgate  Leigh,  re- 
ported by  Werner  (Fort- 
schritte  auf  dem  Gebiete 
der  Rontgenstrahlen, 
Band  iii,  Heft  3),  ob- 
served the  cure  of  tuber- 
culosis of  the  elbow.  The 
exposures  lasted  two 
hours,  and  were  reported 
two  or  three  times  a  week. 
The  total  length  of  the 
period  of  irradiation  was 
twelve  hours.  Then  the 
swelling  had  disappeared 
and  no  relapse  occurred. 
The  time  of  observation 
was  eighteen  months  at 
the  date  of  the  report. 

Kirmisson  ( Societe  de 
chirurgie,  February  2, 
1890)  reported  a  case  of 
tuberculosis  of  the  wrist, 
which  was  much  bene- 
fited by  65  daily  seances, 
each  one  lasting  ten  min- 
utes. The  cure  became 
perfect  under  Bier's  com- 
pression-treatment. Sim- 
ilar results  were  reported 
by  Bazy,  Lancaster,  Sain- 
ton, and  Escherich. 

In  pulmonary  tuber- 
culosis good  results  are 
claimed  by  Rendu  and  Du 
Castel,  Bergonie  and  Mon- 
gour,  Sinapius,  Chante- 
loube,  Descamps,  and  Rou- 
illies,  Destot  and  Dubard. 
Sinapius    (Die  Heilung  der   Lungentuberculose  durch   Rontgen- 


Pig.  317. — Adenoma  op  Tongue. 


SPECIAL    INDICATIONS 


429 


strahlen,  Leipzig,  1897)  claimed  that  he  obtained  a  number  of  ex- 
cellent results.  In  seems,  however,  that  the  diagnosis  was  not 
thoroughly  established  in  these  cases,  therefore  the  deductions 
have  to  be  taken  cum  grano  salis.  In  tuberculosis  of  the  larynx 
the  prospects  of  irradiation  seem  to  be  more  promising. 

The  influence  of  the  Rontgen-rays  was  tried  experimentally  by 
the  author  in  the  case  of  a  boy  of  ten  years,  who  suffered  from 
tuberculosis  of  the  thumb 
(Fig.  316).  Although 
there  was  intense  irra- 
diation, the  improvement 
was  only  slight.  Irra- 
diation in  combination 
with  injections  of  iodo- 
form glycerine  seem  to 
give  the  best  results,  as 
was  also  shown  in  this 
case. 

Lymphoma  has  also 
been  treated  successfully 
by  the  Rontgen  method. 
The  author,  however,  ad- 
vises irradiation  after  re- 
moval. Considerable  in- 
fluence is  also  observed 
in  adenomatous  condi- 
tions (see  Fig.  317).  The 
same  applies  to  the  treat- 
ment of  malignant  lymphoma.  In  the  case  of  a  woman  of  twenty- 
five  years  suffering  from  this  disease  (Fig.  318)  improvement  was 
obtained  bv  irradiation. 


Fig.  318. — Malignant  Lymphoma. 


NEURALGIA 


The  value  of  the  Rontgen-rays  as  an  analgesic  has  been  demon- 
strated in  connection  with  the  treatment  of  malignant  growths. 

Gocht  (Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen, 
Band  i.)  obtained  prompt  relief  from  trigeminal  neuralgia  after 
the  second  exposure.    Freund  observed  similar  results. 


430 


THE    RONTGEN    RAYS 


Stembo  (Die  Tberapie  der  Gegenwart,  1900,  No.  6)  reported 
a  permanent  cure  in  21  eases  of  neuralgia.  Grunmach  (Deutsche 
medicinische  Wochenschrift,  1899,  No.  37)  claims  that  neuralgia 
of  the  face,  occiput,  and  of  the  intercostal  nerves  disappeared. 

In  one  of  the  author's  cases  slight  relief  was  obtained.  The  pa- 
tient, a  man  of  forty  years,  suffered  from  infraorbital  neuralgia. 
After  extensive  resection  of  the  nerve  the  author  observed  a  tem- 
porary cure.  Nine  months  afterward  the  same  pain  recurred. 
Irradiation  was  tried  now  until  reaction  showed  up.     While  the 

dermatitis  lasted  slight  relief 
was  obtained. 

It  seems  that  the  electric 
irritation  of  the  peripheric 
nerves  inhibits  their  function, 
so  that  there  is  no  sensation. 
Whether  the  disappearance  of 
colicky  pains  observed  in  some 
of  the  author's  cases  of  chole- 
lithiasis was  due  to  irradia- 
tion seems  to  be  doubtful. 


NOMA    (CANCRUM  ORIS) 

Recently  the  author  also 
tried  to  study  the  influence  of 
the  rays  on  noma  (cancrum 
oris).  Fig.  319  is  an  illustra- 
tion of  this  horrible  disease 
in  a  girl  of  six  years.  The 
gangrenous  process  followed  a  severe  attack  of  scarlet  fever.  In 
spite  of  using  the  most  radical  means  (exsection  of  the  necrotic 
area,  followed  by  use  of  Paquelin's  cautery,  antiseptic  spray, 
necrotic  foci  formed  again.  It  seemed  that  after  strong  irradia- 
tion the  process  was  checked. 


Fig.  319.— Noma  after  Scaklet  Fever. 


CHAPTEE    XX 
BECQUEREL    RAYS    AND    RADIUM 

It  appears  quite  natural  that  as  the  direct  consequence  of 
Rontgen's  discovery  other  rays  were  detected.  The  Becquerel  rays, 
for  instance  (discovered  by  Becquerel  in  189G),  may  be  regarded 
as  Rontgen  rays  of  small  intensity. 

Uranium  was  discovered  by  Klaproth,  a  German  chemist,  more 
than  a  hundred  years  ago.  Peligot  isolated  the  metallic  uranium 
from  the  chloride  in  1840. 

Becquerel  showed  that  especially  uranium  and  its  salts  are  capa- 
ble of  exciting  fluorescent  screens.  Without  being  stimulated  by 
any  form  of  electricity,  light,  or  heat,  the  Becquerel  rays  can  be 
transmitted  through  wood,  pasteboard,  and  even  thin  metal.  They 
seem  to  he  identical  with  the  Rontgen  rays  in  that  they  discharge 
electrified  bodies,  generate  ozone  in  the  atmosphere,  are  deflected 
by  the  magnet,  and  are  capable  of  exerting  chemical  action. 

The  Becquerel  rays  have  less  penetrative  power  than  the  Ront- 
gen rays,  and  also  show  poor  contrasts ;  so  that  in  their  present 
shape  they  cannot  be  utilized  for  diagnostic  purposes. 

Uranium  is  found  in  very  small  amounts.  It  forms  various 
minerals,  the  commonest  of  which  is  the  uraninite,  better  known 
as  Pitschblende,  a  compound  oxide  which  also  contains  barium, 
iron,  and  other  metals,  and  is  found  in  Saxony,  Bohemia,  England, 
and  Colorado. 

In  1896  Professor  Pierre  Curie  and  Mrs.  Curie,  of  Paris,  suc- 
ceeded in  extracting  the  polonium  from  the  uranium.  Polonium 
shows  greater  radio-activity  than  the  uranium,  and  penetrates 
aluminum  to  a  much  greater  extent.  The  polonium  rays  can  be 
deflected  by  a  magnet  and  lose  their  power  very  rapidly.  It  is 
characteristic  for  uranium  as  well  as  for  polonium  that  they  can- 
not impart  radio-activity. 

Shortly  after  the  discovery  of  polonium  Mr.  and  Mrs.  Curie 
gave  the  world  the  most  mysterious  substance  called  radium.    This 

431 


432  THE    KONTGEN    RAYS 

remarkable  metal  was  isolated  from  the  barium  also  found  in  the 
pitschblende.  Mr.  Curie  regards  the  radium  to  be  a  new  element. 
Of  the  polonium  a  sufficient  quantity  has  not  yet  been  obtained 
to  give  a  spectrum,  wherefore  the  proof  as  to  whether  it  be  a  pure 
element  is  not  brought  yet. 

Although  the  radium  is  called  a  metal  it  does,  in  fact,  not  exist 
in  a  metallic  form,  as  it  is  generally  secured  as  a  bromide  or  a 
chloride. 

The  rays  of  radium  are  capable  of  reducing  peroxide  of  iron, 
bichromate  of  potash,  and  the  salts  of  silver  in  presence  of  organic 
substances.  They  furthermore  colorize  white  paper,  glass,  and 
porcelain,  change  the  greenish-yellow  color  of  platino-cyanide  of 
barium  into  a  brownish  variety,  and  transform  white  into  red 
phosphorus.  It  was  only  natural  to  expect  that  they  would  like- 
wise act  on  the  silver  gelatine-bromide  of  photographic  plates. 

So  far  the  radium  could  be  procured  only  from  the  pitschblende 
found  in  Saxony.  The  greatest  obstacle  to  the  practical  utiliza- 
tion of  the  radium  is  its  enormous  price.  This  deplorable  fact  is 
well  explained  by  the  technical  difficulties  connected  with  its  sepa- 
ration from  the  uranium  residues.  To  produce  only  two  pounds 
of  the  costly  substance  8,000  tons  of  uranium  residue  are  required. 

The  activity  of  radium  as  well  as  of  polonium  and  actinium  is 
a  million  times  greater  than  that  of  uranium.  It  is  most  remark- 
able that  the  temperature  of  radium  is  always  one  and  one-half 
centigrade  over  that  of  the  surrounding  atmosphere.  Thus  it  may 
be  calculated  that  one  hundred  small  calories  are  set  off  by  fifteen 
grains  of  radium  per  hour.  There  are  various  theories  on  the  un- 
known source  of  this  wonderful  energy,  but  so  far  none  of  them 
has  proved  to  be  satisfactory,  the  most  plausible  one  being  that 
there  is  a  property  of  capturing  peculiar  radiations  which  are  cov- 
ering the  space  continuously  without  being  noticed  by  us. 

Another  marvelous  property  of  radium  is  that  its  activity  can 
be  imparted  to  other  substances  which  may  retain  this  activity  for 
varying  periods  of  time.  Curie  reported  that  he  could  not  go  near 
to  his  electrometer  to  make  measurements  for  hours  after  having 
been  near  radium.  Geitel  and  Elster  (Physikalische  Zeit,  II,  p. 
590)  observed  that  a  thin  wire  of  any  metal  which  was  charged 
negatively  from  some  source  of  a  current  became  radio-active. 
The  same  applies  to  lightning-rods,  leaves  of  trees,  falling  rain  or 
snow,  at  least  for  a  time. 


BECQUEREL    RAYS    AND    RADIUM  433 

It  is  natural  that  a  substance  which  excels  by  such  marvelous 
powers  must  also  have  some  marked  physiological  effects.  They 
made  themselves  severely  felt  when  Becquerel  carried  some  radium 
in  his  pocket  and  sustained  a  deep  burn  on  his  abdomen. 

Danyoz  and  London  found  that  mice  were  killed  within  four 
to  five  days  by  the  influence  of  radium,  even  if  this  substance  was 
kept  at  a  distance.  At  first  hyperemia  of  the  ears  was  observed  ; 
later  on  there  was  indifference  to  mechanical  irritation,  and  finally 
coma  and  paralysis  supervened.  It  seems  that  the  function  of  the 
cerebral  nervous  system  is  disturbed  first.  Autopsy  showed  pro- 
fuse hyperemia  of  the 
subtegumental  tissues 
and  of  the  dura  mater. 
The  size  of  the  spleen 
was  greatly  reduced. 

Another  property  of 
radium  is  that  a  tube 
containing     two     or 

three     milligrams     of 

. ,  .  t      p   ^  i  Fig.  320. — Skiagraph  of  a  Key — by   Bromide   of 

this  wonderful  product  Radium 

held   near   one's   tem- 
ple causes  the  sensation  of  a  flash  of  light.     If  held  there  for  a 
few  hours,  dermatitis  will  be  evoked.    When  applied  to  the  nerve- 
centers,  a  paralyzing  effect  is  produced.     This  may  be  so  strong 
that  it  may  kill  organisms  when  inflicted  upon  them. 

Two  milligrams  of  radium  inserted  near  the  vertebra?  of  a  mouse 
caused  death  in  three  hours  by  paralysis,  according  to  Professor 
Curie.  That  the  radium  rays  also  possess  bactericidal  properties 
is  evident  from  the  experiments  of  W.  Caspari,  Asch,  and  Kinass, 
who  observed  that  the  cultures  of  the  bacillus  prodigiosus  were 
destroyed  in  three  hours. 

Blind  people  experience  a  sensation  of  light  as  soon  as  radium 
is  brought  near  the  eyes. 

M.  Javal  (Eevue  Internationale  de  Felectrotherapie  et  de  la 
radiotherapie,  November  and  December,  1902)  finds  that  patients 
afflicted  with  glaucoma  or  corneal  opacity  are  able  to  see  radium 
well,  while  in  case  of  blindness  due  to  changes  in  the  retina,  no 
vision  is  obtained  from  it. 

It  was  obvious  to  utilize  the  physiological  properties  of  radium 
for  therapeutic  purposes.    Undoubted  success  has  been  obtained  in 
29 


434 


THE    RONTGEN    RAYS 


various  diseases,  especially  in  lupus,  carcinoma,  and  sarcoma. 
Some  investigators  claim  that  the  rays  of  the  radium  show  even  a 
greater  therapeutic  effect  than  the  Rontgen  rays,  and  that  they 
reduced  the  extent  of  malignant  growths  in  cases  where  the  Ront- 
gen rays  had  been 
tried  in  vain. 

A  n  undoubted 
advantage  of  the  ra- 
dium over  the  Ront- 
gen rays  is  that  it 
can  be  placed  into 
m  u  c  o  u  s  cavities, 
like  the  nose,  oeso- 
phagus, stomach, 
uterus,  urethra,  etc. 
The  small  size  of 
the  tubes  also  per- 
mits of  embedding 
them  w  i  t  h  i  n  the 
tumourous  tissue 
through  an  opening 
made  hj  puncture. 
The  r  a  d  i  u  m 
treatment  may  also 
be  tried  in  all  cases 
in  which  irradiation 
by  the  Rontgen  rays 
proved  to  be  unsuc- 
cessful. 

In  regard  to  the 
diagnostic      utiliza- 
tion of  the  radium  rays  it  must,  however,  be  said  that  while  there  is 
considerable  permeation,  the  contrasts  are  poor.     Another  disad- 
vantage is  that  it  takes  hours  to  represent  an  image. 

Figs.  320  and  321,  for  instance,  are  skiagraphs  made  by  the  aid 
of  radium.  Fig.  320  (key)  was  taken  with  30  milligrams  of  bro- 
mide of  radium,  the  time  of  exposure  lasting  one  hour.  Fig.  321 
(hand)  is  the  result  of  six  hours'  exposure,  10  milligrams  of  bro- 
mide of  radium  only  being  used. 

The  intense  illuminating  effect  of  the  radium  is  illustrated  by 


Fig.    331. — Skiagkaph    of    Hand— by 
Radium. 


Bromide     of 


BECQUEREL    KAYS    A\I>    RADIUM  435 

the  fact  that  a  sufficienl  amounl  of  it  permits  of  microscopical  ex- 
amination in  a  dark  room. 

Radium  musl  be  kepi  free  from  moisture.  Ii  cannol  be  handled 
in  a  loose  condition,  and  is  therefore  besl  kepi  in  a  sealed  glass 
tube.  While  a  higher  degree  of  temperature  increases  the  lumi- 
nosity of  radium,  moisture  reduces  ii  considerably. 

There  are  other  radio-active  substances  which  were  separated 
from  pitschblende,  as  for  instance  thorium,  which  stands  nexl  to 
radium  as  far  as  radio-activity  is  concerned,  and  actinium,  a  sub- 
stance which  possesses  the  characteristics  of  its  associate,  the 
thorium. 


CHAPTER    XXI 
FIXSEX  METHOD  AXD  ULTRA-VIOLET  RAYS 

The  observations  of  Professor  Xiels  R.  Finsen,  of  Copenhagen, 
on  "Concentrated  chemical  light  rays  in  medicine,"  and  especially 
the  remarkable  results  he  obtained  in  the  treatment  of  lupus, 
startled  the  medical  world.  Since  this  preliminary  report,  pub- 
lished in  December,  1896,  the  number  of  cases  of  lupus  vulgaris  sub- 
jected to  his  method  by  Finsen  swelled  up  to  800. 

Originally  Finsen  simply  utilized  the  rays  of  the  sun,  employ- 
ing the  chemical  or  actinic  rays  only  and  excluding  the  caustic. 

As  is  well  known,  a  large  quantity  of  the  most  effective  radia- 
tion, viz.,  that  of  the  ultra-violet,  becomes  absorbed  in  passing  the 
atmosphere.  It  is  furthermore  appreciated  that  the  sun-rays  cause 
radiant  heat  which  must  be  filtered  off.  These  difficulties  Finsen 
tried  to  overcome  by  utilizing  a  solution  of  ammonio-sulphate  of 
copper  as  a  ray  filter. 

It  soon  became  evident,  however,  that  the  chief  result  was  pro- 
duced just  by  these  ultra-violet  rays,  which  become  absorbed  to  so 
large  an  extent  in  passing  the  atmosphere.  Therefore  Finsen  se- 
lected the  electric  arc  in  place  of  the  sun-rays,  also  substituting 
quartz  as  the  transmitting  medium.  Between  the  quartz  lenses  a 
stream  of  running  water  served  to  absorb  the  heat-rays.  Thus  the 
intensity  of  the  therapeutic  effect  was  increased  while  the  time  of 
exposure  was  shortened. 

The  fact  that  the  common  arc-light  gives  off  a  much  larger 
amount  of  ultra-violet  rays  than  the  sun  was  known  before  it  was 
practically  utilized.  That  it  is  still  far  surpassed  by  the  condenser, 
was  discovered  only  recently  by  Gorl,  of  Xuremberg  (see  Zur 
Lichtbehandlung  mit  ultravioletten  Strahlen,  Muenchener  Medi- 
cinische  Wochenschrift,  May  8,  1901),  who  made  use  of  the  actinic 
qualities  of  the  condenser-spark  by  constructing  the  lamp  which 
is  now  commonly  known  as  the  "  Gorl  lamp/' 

Besides  being  actinic  the  ultra-violet  rays  are  characterized  by 
436 


FINSEN    METHOD    AND    LTLTKA-VIOLET    RAYS    437 

their  power  of  fluorescence.  Their  effect  on  the  integument  of 
higher  animals  and  their  bactericidal  properties  are  also  well 
marked. 

Finsen's  important  observation  that  anaemic  tissues  are  per- 
meated more  readily  by  the  ultra-violet  rays  than  those  in  which 
normal  blood  circulation  takes  place  induced  him  to  advise  com- 
pression of  the  integumental  area,  in  order  to  render  it  as  blood- 
less as  possible  (see  also  Bie,  British  Medical  Journal,  September 
30.  1899.  Thus  a  higher  degree  of  translucency  was  obtained); 
and,  the  greater  the  transparency  of  the  tissues  is,  the  more  power- 
ful the  therapeutic  effect  will  be.  It  is  well  to  remember,  as  shown 
in  the  division  on  the  physiological  effects  of  the  Rontgen  rays 
(p.  360),  that  the  ultra-violet  rays  present  inside  of  a  Rontgen  tube 
do  not  penetrate  the  glass,  wherefore  they  need  no  practical  con- 
sideration in  the  question  of  Rontgen  irradiation.  In  other  words, 
glass  must  be  considered  to  be  opaque,  just  like  bones,  paper,  rub- 
ber, and  ebonite,  while  substances  like  quartz,  ice,  grape-sugar, 
and  pure  polished  rock-salt  are  transparent  to  the  ultra-violet 
rays.  Polished  rock-salt  is  the  most  transparent  substance  of  all, 
and  consequently  best  fitted  for  the  purpose  of  compression. 

Gorl  very  properly,  therefore,  utilized  this  substance  for  his 
lamp,  which  he  attached  with  its  condenser  to  the  secondary  termi- 
nals of  a  Ruhmkorff  coil.  This  modus  operandi  simply  consisted 
then  in  pressing  the  open  end  of  the  Gorl  lamp,  which  is  fitted  with 
a  piece  of  rock-salt  against  the  area  to  be  treated. 

While,  with  the  ingenious  apparatus  of  Finsen,  as  well  as  of 
Lortet  and  Genoud,  a  cooling  medium  is  required  in  order  to  re- 
duce the  radiation  of  heat,  by  which  the  ultra-violet  rays  are  always 
more  or  less  intercepted,  the  Gorl  lamp,  by  virtue  of  its  feeble 
radiation  of  heat,  can  be  used  as  it  is. 

Piffard,  who  deserves  credit  for  having  called  attention  to  the 
therapeutic  properties  of  sun-light  years  ago,  modified  the  Gorl 
lamp  in  such  a  manner  that  its  employment  became  extremely 
simple. 

As  alluded  to  before  this  method  of  treatment  proved  to  be 
especially  successful  in  lupus  vulgaris.  But  also  in  lupus  erythe- 
matodes  and  other  superficial  lesions  of  a  benign  as  well  as  of  a 
semi-malignant  character;  furthermore  in  its  influence  upon  the 
vesicles  of  small-pox  it  also  showed  marked  effects.  This  natu- 
rally brings  up  the  question,  what  advantages  the  Rontgen  ray 


438  THE    RONTGEN    RAYS 

therapy  possesses  over  the  method  of  Finsen.  Of  the  physical 
nature  of  the  latter  we  surely  know  more  than  of  that  of  the  first. 
We  know  that  the  ultra-violet  rays  are  composed  of  the  blue,  violet, 
indigo,  and  ultra-violet  portions  of  the  spectrum,  while  the  nature 
of  the  Roentgen  rays  is  still  X,  that  is  unknown. 

The  ultra-violet  rays,  by  virtue  of  the  short  length  of  their 
waves  and  by  their  high  frequency,  cause  no  sensation  of  light,  like 
the  Rontgen  rays.  Neither  can  the  Rontgen  rays  be  polarized  or 
reflected  and  refracted  like  the  ultra-violet  light.  As  alluded  to  in 
the  general  part  (p.  61)  the  opacity  of  the  Rontgen  rays  depends 
upon  the  density  or  atomic  weight  of  the  objects,  a  factor  which 
does  not  influence  the  penetration  power  of  the  ultra-violet  rays. 
In  proportion  to  the  difference  in  the  physical  manifestations  of 
the  two  kinds  of  light  there  is  a  marked  dissimilarity  in  the  charac- 
ter of  the  inflammatory  and  congestive  reaction.  In  great  contra- 
distinction to  the  Rontgen  light  the  ultra-violet  rays  cause  but  a 
slight  hypersemic  condition,  which  disappears  rapidly.  It  is 
furthermore  a  special  feature  of  the  ultra-violet  rays,  that  these 
symptoms  appear  immediately  after  the  exposure.  Pigmentation 
may  be  produced,  but  no  destruction  of  healthy  tissue,  especially 
no  burns  of  the  third  degree  as  in  Rontgen  irradiation. 

The  fact  that  there  is  so  little  power  of  penetration  shows  that 
the  ultra-violet  rays  can  not  be  considered  as  effective  means  in  the 
treatment  of  malignant  growths. 

In  integumental  affections  of  a  cosmetic  character  the  ultra- 
violet rays  show  an  advantage  over  the  Rontgen  rays,  because  there 
is  no  fear  of  intense  reaction.  They  may,  therefore,  also  be  sub- 
stituted in  such  cases,  where  great  vulnerability  is  shown  under 
Rontgen  ray  treatment. 

The  firm  pressure  which  is  necessary  to  keep  up  angemia  of  the 
irradiated  skin-area  is  a  most  tiresome  procedure,  and  it  requires 
a  great  deal  of  patience  to  submit  to  many  daily  seances  of  an  hour's 
duration. 

All  in  all,  this  mode  of  treatment  can  not,  ingenious  as  it  is, 
in  its  present  state,  compete  with  the  Rontgen  method.  Fig.  322 
illustrates  the  modus  operandi  at  the  Finsen  Institute  in  Copen- 
hagen. The  light  is  thrown  through  large  telescopes  and  concen- 
trated on  the  diseased  areas  which  are  compressed  by  nurses. 

In  this  connection  attention  is  called  to  the  great  credit  due 
to  Dr.  William  J.  Morton,  of  New  York  City,  who  not  only  pub- 


KIXSK.X     METHOD    AND    ULTRA-VIOLET    RAYS     139 

lishecl  the  first  hook  on  the  Rontgen  rays  in  this  country,  but  also 
called  attention  to  the  therapeutic  properties  of  a  form  of  elec- 
tricity called  "high  frequency  current"  as  early  as  1881.  This 
current  is  characterized  by  its  alternating  or  oscillating  at  the  rate 
of  about  one  million  times  a  second,  and  its  powerful  effect  on 
metabolism.  The  principle  of  Morton  was  utilized  and  modified 
by  d'Arsonval  of  Paris. 

In  the  original  Morton  arrangement  there  is  a  spark  gap  of  an 
inch,  while  in  that  of  d'Arsonval  one  of  about  ten  inches  is  used. 


Fig.  322.— Irkadiation  by  Finsen  Ltght. 


When  the  d'Arsonval  current  passes,  the  patient  feels  a  vibrating 
sensation  first  and  his  hair  stands  out  from  the  scalp.  Then  there 
is  a  feeling  of  exhilaration  and  increasing  energy. 

What  changes  the  passing  currents  induce  in  the  tissues  is  still 
unknown.  Mysterious  as  the  Kontgen  rays  and  the  radium  are, 
their  discovery  meant  only  another  new  riddle,  which  may  never 
be  solved. 


BIBLIOGRAPHY 


Abbe,  R. — Eenal  Calculi.     Annals  of  Surgery,  August,  1899. 
Albers-Schonberg — Lupus    des    Handriickens    durch    Bontgenstrahlen 
geheilt.     Hamburg,  29  Maerz,  1898. 

—  Ders.  Zur  Technik  der  Nierensteinaufnahme,  Fortschritte  d.  R.  iii. 

210. 

—  Ders.  Die  Bontgentechnik.    Hamburg,  Lucas  Grafe  und  Sillem,  1903. 
Allen,  Charles  Warrenne — The  Nature  of  Cutaneous  Epithelioma  and 

Eemarks  on  X-Eay  Treatment.     New  York  Medical  Eecord,  Jan- 
uary 25,  1902. 

—  Eadiotherapy  in   Cancer  and  Skin  Diseases.     The  New  York  State 

Journal  of  Medicine,  June   1,  1902. 

—  The   Early   Diagnosis  and   Early   Treatment   of   Cutaneous    Cancer. 

The  Medical  Examiner  and  Practitioner,  September,  1902. 

—  Eesults  in  Fifty  Cases  of  Cancer  treated  with  the  Aid  of  Eontgen 

Eays.     New  York  State  Journal  of  Medicine,  July,  1903. 

—  The  X-Eay  in  Cancer  and  Skin  Diseases.     The  Journal  of  Cutaneous 

Diseases,  February  21,  1903. 

—  Eecent  Advances  in  Cutaneous  Therapy.     Journal  of  the  American 

Medical  Association,  June  3,  1903. 

—  The   Treatment   of   Cutaneous   Epitheliomata.      New   York    Medical 

Journal,  November  9,  1901. 

—  The  Value  of  Eadiotherapy  in  Cutaneous  Diseases  and  Cancers  of  the 

Skin.    Eead  at  Fourteenth  International  Congress,  Madrid,  April 
23,  1903. 

—  The  Present  Status  of  Eadiotherapy  in  Cutaneous  Diseases  and  Can- 

cer.    Medical  Eecord,  November  15,  1902,  p.  176. 
American  X-Eay  Journal,  St.  Louis,  Mo. 

Apostoli  and  Planet — Eontgendermatitis.    Presse  Medicale,  1897,  No.  64. 
Archives  d'electricite  medicale.    Ferret  et  Fils,  Bordeaux. 
Archives  of  the  Eontgen  Eay.     Eebman,  Limited,  London,  W.  C. 
D'Arsonval,  Lumiere  noire,  Ac.  des  sciences,  17.     February,  1897. 
Barwell — Clubfoot.     Lancet,  1897,  pp.  306  and  1401. 
Beck,   Carl — Skiagraphic   Eepresentations.      Transactions    of   the   New 

York  Eastern   Medical   Society,  March,  1896. 

—  The  Eontgen  Eays  in  Surgery.    Surgical  Section  of  the  Second  Pan- 

American  Congress,  Mexico,  November  9,  1896. 

—  Pyothorax     (with    Eontgen    Eay    Demonstrations) .      International 

Medical  Magazine,  January,  1897. 

440 


BIBLIOGRAPHY  441 

Beck,    Carl— The    Rontgen    Rays    in    Surgery,      International    Medical 
Magazine,  May,  1897. 

—  Ueber  den  diagnostichen  Wert  der  Rontgenstrahlen  bei  der  Arteri- 

osklerose.     Deutsche  medicinische  Wochenschrift,   1898,   No.  7. 

—  The  Rontgen  Rays  in  Arteriosclerosis.     New  York  .Medical  Journal, 

January  17,  1898. 

—  Zur  Behandlung  des  Pyothorax.    Berliner  klinische  Wochenschrift, 

1898,  Nr.  15  unci  16. 

—  Ueber   die    Bedeutung   der    Rontgenstrahlen    bei    der    Spina    bifida. 

Deutsche  medicinische  Wochenschrift,  1898,  No.  31. 

—  An  Extraordinary   Case   of   Aortic   Aneurysm.     New   York    Medical 

Journal,  April  15,  1898. 

—  Colles's  Fracture  and  the  Rontgen  Rays.     Medical  News,  February 

19,    1898. 

—  The  Rontgen  Rays  in  Spina  Bifida.     New  York  Medical  Record,  Au- 

gust 13,  1898. 

—  Fracture  of  Humerus.     Archives  of  the  Bontgen  Ray,  August,  1898. 

—  Osseous   Ankylosis   of  Knee-joint.     Archives   of  the    Rontgen   Ray, 

February,  1898. 

—  Skiagraphic  Demonstrations.     American   X-Ray  Journal,  November 

1898. 

—  Renal  Calculi.    Am.  Journal  of  Cut.  and  Gen.-Ur.  Diseases,  January, 

1899. 

—  A  Case  of  Transposition  of  the  Viscera,  with  Cholelithiasis,  relieved 

by  a  Left-sided  Cholecystostomy.    Annals  of  Surgery,  May,  1899. 

—  Fracture  of  the  Lower  End  of  the  Radius.    New  York  Medical  Jour- 

nal, September  9  and  23,  1899. 

—  Ueber  die  moderne  Behandlung  von  Frakturen.     New  Yorker  medi- 

cinische  Wochenschrift,   January,    1900. 

—  On  a  Grave  Possible  Error  in  Skiagraphy.    New  York  Medical  Jour- 

nal, January  6,  1900. 
— ■  On  the  Detection   of  Calculi  in   the  Liver  and   Gail-Bladder.     New 
York  Medical  Journal,  January  20,   1900. 

—  Hydrencephalocele.     Section  on  Diseases  of  Children,  Annual  Meet- 

ing of  the  Am.   Med.  Association,  Atlantic  City,  N.  J.,  June  5, 
1900. 

—  Die   Bedeutung   und    Behandlung   der   Kniescheibenbruche    in    Mo- 

derner  Beleuchtung.     New   Yorker   medicinische   Monatsschrift, 
July,  1900. 

—  Contribution  to  the  Therapy  of  Encephalocele.    International  Medi- 

cal Magazine,  August,  1900. 

—  On   the    Treatment   of    Metacarpal   Fracture.      New    York    Medical 

Journal,  August  4,  1900. 

—  Errors   Caused  by   the  False  Interpretation   of  the   Rontgen   Rays, 

and   their   Medico-Legal   Aspects.      New   York    Medical    Record, 
August  25,  1900. 

—  Ueber    Irrtiimer    der    Rontgographie.      Deutsche    Medicinalzeitung, 

1900,  No.  51, 


442  THE    RONTGEN    RAYS 

Beck,   Carl — Ueber   Tendinitis   und   Tendovaginitis   Prolifera   Calcarea. 
Deutsche  Zeitschrift  fiir  Chirurgie,  Bd.  lviii. 

—  Beitrag    zur    Fraktur    der    karpalen    Radiusepiphyse.      Archiv    fiir 

klinische  Chirurgie,  63.  Bd.,  Heft.  1. 

—  The  Representation  of  Biliary  Calculi  by  the  Rontgen  Raj's.     New 

York  Medical  Journal,  March  16,  1901. 

—  Fissure  of  the  Head  of  the  Radius.     Annals  of  Surgery,  April,  1901. 

—  Die  Rontgenstrahlen  in  Amerika.     Miinchener  med.  Wochenschrift, 

No.  9,  1901. 

—  Metatarsal  Fracture.     American  Medicine,  April    1901. 

—  Ueber    Deform    Geheilte    Frakturen    und    ihre    Behandlung.      Miin- 

chener medicinische  Wochenschrift,  No.  17,  1901. 

—  Osseous  Cyst  of  the   Tibia.     Am.  Journal  of  the  Medical   Sciences, 

June,  1901. 

—  Ueber    die    Darstellung    von    Gallensteinen    mittelst    der    Rontgen- 

strahlen, nebst  Bemerkungen  iiber  die  Erblichkeit  der  Predis- 
position zur  Gallensteinkrankheit.  Berliner  klinische  Wochen- 
schrift, No.  19,  1901. 

—  Ueber     Sarkombehandlung    mittelst    der    Rontgenstrahlen.       Miin- 

chener medicinische  Wochenschrift,  No.  32,  1901. 

—  On   Tenonitis   and   Tenontothecitis   Prolifera  Calcarea.     New   York 

Medical  Journal,  April  27,  1901. 

—  Hydrencephalocele.     Archives  of  the  Rontgen  Ray,  August,  1901. 

—  Beitrag  zur  Diagnostik  und  Therapie  der  Struma.     Fortschritte  auf 

dem  Gebiete  der  Rontgenstrahlen,  Band  iv. 

—  Congenital    Malformations    of    the    Upper    Extremity.      New    York 

Medical  Journal,  June  29,  1901. 

—  Fracture  of  the  Carpal  End  of  the  Radius,  with  Fissure  or  Fracture 

of  the  Lower  End  of  the  Ulna,  and  Other  Associated  Injuries. 
Annals  of  Surgery,  August,  1901. 

—  On  a  Case  of  Double  Penis,  combined  with  Exstrophy  of  the  Bladder 

and  showing  Four  Ureteral  Orifices  (with  Skiagraphic  Demon- 
stration).    Medical  News,  September  21,  1901. 

—  Modern  Aspects  of  Congenital  Osseous  Malformations.     Journal  of 

the  American  Medical  Association,  October  12,  1901. 

—  Some  New  Points  in  Regard  to  Raynaud's  Disease.    American  Jour- 

nal of  the  Medical  Sciences,  November,   1901. 

—  Ueber  tuberkulose  Halsdriisen.     New  Yorker  medicinische  Monats- 

schrift,  November,   1901. 

—  Ueber  die  Fissuren  am  oberen  Humerusende.     Fortschritte  auf  dem 

Gebiete  der  Rontgenstrahlen,  Band  iv. 

—  The  Rontgen  Rays  in  Differentiating  between  Osteomyelitis,  Osse- 

ous Cyst,  Osteosarcoma,  and  Other  Osseous  Lesions,  with  Skia- 
graphic Demonstrations.  Fifty-second  Annual  Meeting  of  the 
American  Medical  Association,  June  3,  1901. 

—  Ueber  die  Skiagraphische  DifPerentialdifignose   zwischen   Osteomye- 

litis, Osteosarkom,  Knochencyste,  Tuberkulose,  Arthritis,  etc. 
Miinchener  medicinische  Wochenschrift,  August  27,  1901. 


BIBLIOGRAPHY  143 

Beck,  Carl  The  Difficulty  of  Differentiating  between  femoral  Aneu- 
rysm and  Osteosarcoma.  International  Clinics,  vol.  iv,  ninth 
series. 

—  The  Evidence  of  the  Rontgen   Kays  in  Court.     Transactions  of  the 

State  Medical  Society  of  .New  Jersey,  L901. 

—  Die    Fraktur    des    Processus    Coronoideus    Ulnae.      Deutsche    Zeit- 

schrift  fur  Chirurgie,  July,  1901. 

—  Sarcoma   Treated   by    the    Rontgen    Kays.      New     York   .Medical   Jour- 

nal, November  16,  1901. 

—  On  the   Differentiation   between    Inflammatory    Processes  and    Neo- 

plasms of  the  Bones  by  the  Rontgen  Kays.  Annals  of  Surgery, 
December,  1901. 

—  Frakturen,  Lehrbuch  der,  mit    Einem  Anhang  iiber  die   Praktische 

Anwendung  der  Rcintgenstrahlen.  Saunders  &  Co.,  London  and 
Philadelphia,  May,  1900. 

—  Die  Rontgen strahlen  im  Dienste  der  Chirurgie.     Seitz  und  Schauer, 

Miinchen,  1902. 

—  The  Pathologic  and  Therapeutic  Aspects  of  the  Effects  of  the  Ront- 

gen Rays.     Medical  Record,  January    18,   1902. 

—  On  the  Treatment  of  Fracture  of  the   Anatomical   Neck  of  the   Hu- 

merus by  the  Aid  of  the  Rontgen  Rays.  New  York  Medical  Jour- 
nal, April  5,  1902. 

—  Beitrag  zum  anatomischen  Yerstaendniss  der  Fraktur  des  Condylus 

externus  humeri  waehrend  der  Entwickelungsperiode.  Fort- 
schritte  auf  dem  Gebiete  der  Rontgenstrahlen.  Lucas  Griife  und 
Sillem,  Hamburg,  Band  v. 

—  The  Pathology  of  the  Tissue  Changes  caused  by  the  Rontgen  Rays, 

with  special  reference  to  the  treatment  of  malignant  growths. 
New  York  Medical  Journal,  May  24,  1902. 

—  The   Medico-Legal    Value   of   the    Rontgen    Bays.     Medical    Record, 

August  9,  1902. 

—  The   Value  of  the   Rontgen   Bays  in   the  Treatment    of   Carcinoma. 

Medical  Review  of  Beviews,  August,  1902. 

—  The    Principles    of    Protection    against    Bontgen-light    Dermatitis. 

Medical  Becord,  November  18,  1902. 

—  The    Modern    Treatment    of    Fracture    of    the    Lower    End    of    the 

Badius,  as  indicated  by  the  Bontgen  Bays.  Medical  News,  Sep- 
tember 20,  1902. 

—  The  Operative  Treatment  of  Deformed  Fractures  as  indicated  by  the 

Bontgen  Bays.     New  York  Medical  Journal,  December  27,  1902. 

—  The    Treatment   of    Fractures   of    the    Lower    End    of    the    Badius. 

Journal  of  the  American  Medical  Association,  1902. 

—  Exploratives  Princip  und   Technik  beim  secundaeren  Brustschnitt. 

Archiv  fur  klinische  Chirurgie,  v.  Esmarch  Festschrift,  1903. 
— ■  The  Beposition  of  Fractured  Fragments,  with  special  reference  to 
the  Treatment  of  Pott's  Fracture.    Interstate  Med.  Journal,  De- 
cember, 1902. 

—  Inflammatory    Atrophy.      International    Journal    of    Surgery,    May, 

190?,. 


444  THE    KONTGEX    EAYS 

Beck,  Carl — Ueber  achte  Cysten  der  langen  Boehrenknochen.     Archiv 
fiir  klinische  Chirurgie,  Bd.  70,  Heft  4. 

—  Humero-acromial  Suture  for  Habitual  Dislocation  of  Shoulder.    New 

York  Medical  Journal,  July  11,  1903. 

—  Zum  Selbstschutz  bei  der  Kontgenuntersuchung.     Berliner  klinische 

Wochenschrift,  1903,  No.  32. 
- —  The  Bontgen  Baj's  in  Medicine.     Twentieth  Century   Bractice,  vol. 
xxi,   1903. 

—  Osseous  Cysts.    The  Bost -graduate,  September,  1903. 

—  Eine   einfache    Stellrohrblende.     Miinchener   medicinische   Wochen- 

schrift, No.  41,  1903. 

—  On  Last  Year's  Brogress  in  Surgery.  Medical  News,  October  10,  1903. 

—  The  Osteoscope.     New  York  Medical  Journal,  November  28,  1903. 
Becker — Bontgenverfahren   in  der  Medicin.     Deutsche   med.   Wochen- 
schrift, 1896,  No.  27. 

Beclere — Baris,  Les  rayons  de  Bontgen  et  le  diagnostic  des  affections 

thoraciques.     T.  B.  Baillere  et  fils.     Baris,  1901. 
Becquerel — Experiments  en  radium,  Comptes  Bendus,  129,  p.  913,  1899. 
Behn — Einrichtung  zur  Aufzeichnung  des  mit  senkrechtem  Eontgen- 

strahl   hergestellten  Herzschattens.     Eortschritte  d.  B.  iv,  44. 
Benedikt — Die  Herzthatigkeit  in  Bontgenbeleuchtung.     Vereinsbeilage 

zur  Deutschen  medicinischen  Wochenschrift,  1896,  No.  28,  S.  188. 
Bergmann  von — Durch  Bontgenstrahlen  im  Hirn  nachgewiesene  Ku- 

geln.     Berliner  klinische  Wochenschrift,  1898,  No.  18. 

—  Die  Errungenschapten  der  Badiographie  fiir  des   Behandlung  chi- 

riirgseher    Krankheiten,    11.      Yersammelung    deutscher    Natiir- 

fosscher  und  Acrozte  in  Mtinchen. 
Bergmann,   von,  von  Bruns,  und  von  Mikulicz — Handbuch  der   Brak- 

tischen  Chirurgie.     Stuttgart,  1903. 
Boas    und   Levy-Dorn — Zur  Diagnostik   van   Magen-   und    Darmkrank- 

heiten  mittelst  Bontgenstrahlen.     Deutsche  med.  Wochenschrift, 

1898,  No.  2. 
Bouchard — La   pleuresie    de   l'homme   etudiee   a  l'aide   des   rayons   de 

Bontgen.     La  Semaine  Medicale,  1897,  pp.  494,  513,  and  522. 
Braatz — Beitrag  zur  Hirnchirurgie;   Kugelextraktion  aus  dem  Gehirn 

mit  Hilfe   des   Bontgenverfahrens.     Centralblatt   fiir   Chirurgie, 

January  8,  1898. 
von  Bruns  und  Honsell,  Akute  Ostcomiyclitis  im  Gebiet  des  Hiiftgel- 

enks,  Bruns  'sche  Beitrage,  1899,  Bd.  28,  pag.  221. 
Biittner    und    Miiller — Technik    und    Verwertung    der    Bontgen'schen 

Strahlen    im    Dienste    der    arztlichen    Braxis    und    Wissenchaft, 

Halle,  a.  S.,  1897. 
Caldwell — Liquid   Interrupter.     New   York   Electrical   Beview,   May   4, 

1899. 
Camp,    de   la — Ein  Beitrag  zur  Myositis  ossificans.     Fortschritte   auf 

dem  Gebiete  der  Bontgenstrahlen,  Heft  5,  p.  179. 
Chipault  et  Londe — Applications  de  la  Badiographie  &  la  Chirurgie  du 

Systeme  Nerveux.    Gazette  des  Hopitaux,  16,  ii,  1897, 


BIBLIOGEAPHY  445 

Cleaves,  M.  A. — The  Rontgen  Kay  and  Utra-violet  Light  in  the  Treat- 
ment of  Malignant  Diseases  of  the  Uterus,  with  Report  of  an 
Inoperable  Case.     Medical  Record,  December  13,  1902,  p.  :>::]. 

Codman,  E.  A. — A  Study  of  the  Cases  of  Accidental  X-Ray  Burns  Hith- 
erto Recorded.     Philadelphia  Medical  Journal,  1902,  ix,  p.  438. 

Coley,  W.  B. — The  Influence  of  the  Rontgen  Rays  upon  the  Different 
Varieties  of  Sarcoma.    American  Medicine,  1902,  iv,  p.  251. 

—  Treatment    of    Cancer     (including    Sarcoma).      Twentieth    Century 

Practice  of  Medicine,  xxi,  Supplement,  p.  759. 

—  Treatment  of  Malignant  Growths.     Medical  Record,  March  21,   1903. 
Corson,  a  skiagraphic  study  of  the  normal  membra]  epiphysis  at  the 

thirteenth  year.     Annals  of  Surgery,  November,    1900. 

Courmelles — Traite  de  Radiographic  Medicale  et  Scientifique.  Paris, 
1897. 

Cowl  und  Levy-Dora — Ueber  die  Sichtbarkeit  der  Rontg-enstrahlen. 
Verhandlungen  der  Berliner  physiologischen  Gesellschaft.  7 
May  und  25  Juni,  1897. 

Curie,  P.  and  B.  Sagnao,  Rayons  sec.  Comptes  Rendus,  130,  p.  1013, 
1900. 

Deaver — Three  Cases  of  Swallowed  Foreign  Bodies  located  by  the 
Rontgen  Rays.     Annals  of  Surges,  January,  1898,  p.  64. 

Delavan,  D.  B. — The  Results  of  Treatment  of  Laryngeal  Cancer  by  the 
X-Ray.  Transactions  of  the  American  Laryngological  Associa- 
tion, 1902,  p.  188. 

Delbet — Trois  Cas  d'Application  Chirurgicale  des  Rayons  de  Ront- 
gen.    Comptes  Rendus,  23,  II,  1896. 

Destot — Sur  les  causes  de  la  dermatite  radiographique.  La  Radio- 
graphie,  10,  viii,  1899. 

Donath — Die  Einrichtungen  zur  Erzeugung  der  Rontgenstrahlen  und 
ihr  Gebrauch,  Berlin,  1899. 

Dumstrey  und  Metzner — Die  Untersuchung  mit  Rontgenstrahlen. 
Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  1898,  Heft  4, 
p.   115. 

Eiselsberg,  von,  und  Ludloff — Atlas  klinisch  wichtiger  Rontgenphoto- 
gramme.     Berlin,  1900. 

Eulenburg — Kugeln  im  Gehirn,  ihre  Aufnndung  und  Ortsbestimmung 
mittelst.  Rontgenstrahlenaufnahmen.  Deutsche  medicinische 
Wochenschrift,  Xr.  33  und  34,  1896. 

Ewald — Aneurysma  Arcus  Aortae.  Berliner  medicinische  Gesellschaft, 
10,  November  18,  1897. 

Ekner,  Rontgenbehandlung  und  Tumoren,  Wiener  Klinische  Wochen- 
schrift, 1903,  Nr.  25. 

Fenwick — The  Rontgen  Rays  in  the  Detection  of  Renal  Calculi.  Brit- 
ish Medical  Journal,  October  16,  1897. 

Ferguson,  G.  B. — Unfinished  Case  of  Recurrent  Cancer.  British  Med- 
ical Journal,  February  1,  1902. 

Finsen — Om  Anvendelse  i  Medicinen  af  Koncentrerede  Kemiske  Lys- 
straaler.     Kopenhagen   Gyldendelske  Boghandel,   1896. 


446  THE    RONTGEN    RAYS 

Finsen — Mittheilungen  aus  Finsens  Medicinske  Lysinstitut  in  Kopen- 
hagen,  Deutsch  Herausgegeben  von  Dr.  Valdemar  Bie,  Verlag 
von  F.  C.  W.   Yogel,  Leipzig,  1903. 

Fortsehritte  anf  clem  Gebiete  der  Bontgenstrahlen,  herausgegeben 
von   Albers-Schonberg,  Hamburg. 

Freund,  Leopold — Grundriss  der  Gesammten  Badiotherapie.  Wien,  Ur- 
ban und  Schvvarzenberg,  1903. 

Fridenberg — The  Localization  of  Foreign  Bodies  in  the  Eye  by  Means 
of  the  X-Kay.    New  York  Medical  Becord,  li,  20,  p.  694. 

Fuchs,  Chicago — Bontgen  ray  apparatus,  American  X-Bay  Journal, 
October,  1901. 

Gilchrist — A  Case  of  Dermatitis  due  to  X-Bays.  Bulletin  of  the  Johns 
Hopkins  Hospital,  viii,  71,  February,  1897. 

Gocht — Lehrbuch  der  Bontgenuntersuchung  zum  Gebrauch  fur  Medi- 
ciner,  Stuttgart,  Verlag  von  Ferdinand  Enke,  1898. 

—  Seltenere    Frakturen    in    Bontgenscher    Durchleuchtung-Mittheilun- 

gen  aus  den  Hamburger,  Staatskrankenhausanstalten,  1897,  Bd. 
1,  Heft  2. 

—  Therapeutische  Verwendung  der  Bontgenstrahlen,  Fortsehritte  auf 

dem  Gebiete  der  Bontgenstrahlen,  1897,  Bd.  1,  Heft  1. 

—  Verkalkte    Muskeltrichinen    rontgographisch   dargestellt.    Die    Um- 

schau,  2.     Jahrgang,  1898;  No.  39. 

—  Anklage  wegen  fahrlaessiger  Koerperverletzung,   Forts,  a.   d.  G.  d. 

B.,  Bd.  II,  Heft  3. 

—  Ein  neuer  selbstthaetiger  Entwicklungsapparat,  Forts,  a.d.  G.d.  B., 

Bd.  V.  Heft  1. 

Golebievvski — Atlas  und  Grundriss  der  Unfallheilkunde.  J.  F.  Leh- 
mann,  Miinchen,  1900. 

Goodspeed — Bontgen's  Discovery.     Medical  News,  lxviii,  7,  1896. 

Greenleaf,  C.  A. — The  Therapeutic  Value  of  the  X-Bay  in  Lupus  Vul- 
garis.    Buffalo  Medical  Journal,  October,  1901,  p.  189. 

Grunmach — Ueber  die  Diagnostik  innerer  Krankheiten  mit  Hilfe  der 
Bontgenstrahlen.  Wiener  medicinische  Wochenschrift,  1897, 
No.  36. 

Hahn  und  Albers-Schonberg — Die  Therapie  des  Lupus  und  der  Haut- 
krankheittn  mittelst  Bontgenstrahlen,  Miinchener  med.  Wochen- 
schrift, 1900,  No.  10. 

Hall,  Edwards  J. — On  the  Therapeutic  Effects  of  Light  and  the  X-Bays. 
Birmingham  Medical  Beview,  1902,  li,  pp.  334-350. 

Halsted,  W.  S. — A  Contribution  to  the  Surgery  of  Foreign  Bodies. 
Johns  Hopkins  Hospital  Beports,  vol.  ix. 

Hazleton,  E.  B. — X-Bays  in  the  Treatment  of  Bhthisis.  Lancet,  Janu- 
ary 11,  1902,  p.  121. 

Hemmeter,  John,  1  hotography  of  the  human  stomach  by  the  X-Bays. 
Boston  Med.  and  Surg.  Journal,  exxxiv,  25,  1896. 

Heyerdahl,  S.  A. — Om  Bontgenstraalerne  og  deres  praktiske  anven- 
delse  i  medicinen.  Norsk.  Mag.  f.  Laegevidensk,  1898,  4.  It., 
xiii,  pp.  697-721. 


BIBLIOGRAPHY  447 

Ilearn,  VV.  J. — The  Action  of  X-Rays  on  Inoperable  Cancer.    Annals  of 

Surgery,  x\w  i,  |).  293. 
Bildebrandt,     Ueber    Amputationstumpfe.      Deutsche    Zeitschrifl     Eiir 

Chirurgie,   L899,  Bd.  51,  p.  121. 
Hoffa — Die  Redression  des  Buckels  nach  der  Methode  Calot.     Deutsche 

medicinische  Wochenschrift,  1898,  No.  3. 

—  Ueber   Verkriimmungen    des    Beins    nach    Kniegelenksresektion    im 

Kindesalter.  Beitrage  zur  klinische  Chirurgie,  Bd.  xxxvii,  l.  u.  :>.. 
Heft. 

Hofmeister — Ueber  Wachsthumsstorungen  des  Beckens  bei  friihzeitig 
erworbener  Hiiftgelenkscontractur.  Beitrage  zur  klinische  Chi- 
rurgie, Band  xix,  Heft  2,  p.  261. 

Holzknecht — Zum  radiographischen  Verhalten  pathologischer  Pro- 
cesse  der  Brustaorta.  Wiener  klinische  Wochenschrift,  1900. 
No.  25. 

—  Die  Rontgenologische  Diagnostik  •  der   Erkrankungen  der  Brustein- 

geweide.     Hamburg,  Lucas  Grafe   und  Silleni,   1901. 
Hopkins,  George  G. — Light  and  Radiance  in  the  Treatment  of  Disease. 

Philadelphia  Medical  Journal,  April  5,  1902.  p.  626. 
Huebler — Rontgenatlas.     Verlag  von  Gerhard  Kuethmann  in  Dresden, 

1901. 
Immelmann — Controlle    der    Pneumotherapie.    Deutsche    medicinische 

Wochenschrift,  1897,  Therapeutische  Beilage,  p.  67. 

—  Rontgenatlas  des  normalen  menschlichen  Koerpers.     Berlin,  1900. 
Jankau,    L. — Die    schaedlichen    Nebenwirkungen    der   Rontgenstrahlen 

bei  Durchleuchtung  und  Photographie.  Internat.  Photograph- 
ische  Monatsschrift  fiir  Medicin,  1898,  v,  p.  1. 

Jedlicka,  R.,  Kratzenstein,  G.,  und  Seheffer,  W. — Die  topographische 
Anatomie  der  oberen  Extremitaten.  Hamburg,  Lucas  Grafe  und 
Sillem,   1900. 

Jicinsky-Rudiz. — The  X-Rays  in  the  Treatment  of  Malignant  Growths. 
New  York  Medical  Journal,  1902,  lxxvi,  p.  370. 

Joachimsthal — Atlas  der  normalen  und  pathologisehen  Anatomie. 
Hamburg,  Lucas  Grafe  und  Sillem,  1900. 

Johnson,  Wallace,  and  Merrill— The  X-Rays  in  the  Treatment  of  Car- 
cinoma.    Philadelphia  Medical  Journal,  1900,  vi,  p.  10S9. 

Joseph — Biologische  Wirkung  der  Rontgenstrahlen  f.  Alopecia  areata. 
Wiener   klinische    Rundschau,    1901,    No.    41. 

Judd,  L.  D.— Rontgen-Ray  Injuries.  Philadelphia  Medical  Journal, 
1899,  iv,  p.  587. 

Jutassy — Naevus  Flammeus.  Fortschritte  auf  dem  Gebiete  der  Ront- 
genstrahlen, Bd.  ii,  Heft  6. 

Kahleyss— Beitrag  sur  Kenntniss  der  Frakturen  am  unteren  Ende  des 
Radius.     Deutsche  Zeitschrift  fiir  Chirurgie,  xlv,  p.  53. 

Karewski,  p]mpyem,  27  Kongress  der  ges.  f.  Deutsche  Chirurgie,  1898. 

Keen — The  Rontgen  Rays  in  Surgical  Diagnosis.  Am.  Journal  of  Med. 
Sciences,  Sc.  cxi,  3,  1896. 

Kienboeck — Auf    dem     Rontgenschirm     beobachtete    Bewegungen     in 


448  THE    EOXTGEN    BAYS 

einera  Pyopneumothorax.    Wiener  klinische  Wochenschrift,  1898. 
No.  22. 
Kienboeek  —  Hautveraenderungen      durch      Rontgenbestrahlung      bei 
Mensch  und  Thier.    Wiener  medicinische  Presse,  1901,  xlii,  p.  874. 

—  Zur    radiographischen    Anatomie    und    Klinik    der    syphilitischen 

Knochenerkrankungen    und    Extremitaten.      Zeitschr.   fiir   Heil- 

kunde,  June,  1902,  Bd.  xxiii,  Heft  6. 
Koenig — Die  Bedeutung  des  Rontgenbildes  fiir  die  operative  Behand- 

lung    der    tuberkulosen   Coxitis.     Deutsche   Zeitschrift   fiir    Chi- 

rurgie,  1898,  Heft  4. 
Kohler,    Alban — Knochenerkrankungen    im   Rontgenbilde,    Wiesbaden, 

1901. 
Kuemmell — Die  Behandlung  des  Lupus  mit  Rontgenstrahlen  und  mit 

konzentriertem  Licht.     Berliner  Chirurgencongress,  April,  1898. 

—  Die  Rontgenstrahlen  im  Dienste  der  praktischen  Medicin.     Berliner 

klinische  Wochenschrift,  38,  p.  4. 
Kuemmell  und  Rumpel — Chirurgische  Erfahrungen  iiber  Nierenkrank- 

heiten  unter  Anwendung  der  Neueren  Untersuchungsmethoden. 

Beitrage  fiir  klinische  Chirurgie,  Bd.  37,  Heft  3. 
Kuettner — Ueber  die  Bedeutung  der  Rontgenstrahlen  fiir  die  Kriegschi- 

rurgie,  Tubingen,  1897. 
Lambertz — Die  Entwicklung  des  menschlichen  Knochengeruestes  wah- 

rend   des  foetalen  Lebens.     Hamburg,   Lucas  Grafe  und   Sillem, 

1900. 
Lancashire,  G.  H. — The  Therapeutic  Employment  of  X-Rays.     British 

Medical  Journal,  1902,  i,  p.  1328. 
Lannelongue — Application   des   Rayons  X  au  Diagnostic  des  Maladies 

Chirurgicales.     Comptes  Rendus,  23,  lv,  1896. 
Lauenstein,  Nierensteine,  Forts,  a.  d.  G.  d.  R.,  Bd.  iii,  Heft  6,  p.  211. 
Leonard,   C.   L. — Rontgen   Ray  Dermatitis.     American   X-Ray  Journal, 

November,  1898,  p.  453. 

—  Renal  Calculi.     Philadelphia  Medical  Journal,  November  18,  1900. 
Levy-Dorn — Die   Rontgenstrahlen   vor    der    Staatsanwaltschaft.   Aerzt- 

liche  Sachverstaendigen  Zeitung,  1898,  No.  6. 

—  Versuche  tiber  Sekundaerstrahlen.     Physikalische  Zeitschrift,   1899, 

Bd.  i. 
Lexer,  E. — Die  Entstehung  entzuendlicher  Knochenherde  und  ihre  Be- 

ziehung   zu   den   Arterienverzweigungen   der   Knochen.     Archiv. 

fiir  klinische  Chirurgie,  Bd.  21,  erstes  Heft. 
Lloyd,  Samuel — X-Ray  burns.     Medical  Record,  April  4,  1903,  p.  554. 
Lorenz,  A. — Angeborene  Hiift-luxationen,  XXVIII  Kongress  der  Deut- 

schen  Gesellschaft  fiir  Chirurgie,  Berlin,  5.    April,  1899. 
Lustgarten — Rontgen   Dermatitis.   Journal   of   Cut.   and   Gen.-Ur.   Dis., 

p.  525,  1897. 
Maier — Wellenlaenge     der      Rontgenstrahlen.       Miinchener     Inaugur. 

Dissertation,  1901. 
Macintyre — Rontgen  Rays:     Photographs  of  Renal  Calculus,  Descrip- 


BIBLIOGRAPHY  449 

tion  of  an  Adjustable  Modification  in   the  Focus  Tube.     Lancet, 

July    11,  1896. 
Macintyre — The  Value  of  Light,  Rontgen  Kays,  etc.,  in  the  Treatment 

of   Lupus,  Rodent  Ulcer,  and   Cancer.     British  Medical   Journal, 

1902,  ii,  p.  1344. 
Meek,  E.  R. — A  Variety  of  Skin  Lesions  Treated  by  the  X-Rays.    Boston 

Medical  and  Surgical  Journal,  1902,  exlvii,  p.  152. 
Mikulicz,  I.,  von — Mit  Rontgenstrahlen  erfolgreish  behandelter  Brust- 

driisenkrebs.     Beitrage  fiir  klinischen  Chirurgie,  Bd.  37,  Heft  3, 

1903. 
Monell,  S.  H. — A  System  of  Instruction  in  X-Ray  .Methods  and   Medical 

Uses  of  Light,  Hot-air  Vibration,  and  High-frequency  Currents. 

Pelton,  New  York,   1902. 
Moritz — Eine  Methode  um  beim  Rontgenverfahren  aus  dem  Schatten- 

bilde   eines   Gegenstandes   dessen    wahre   Groesse    zu    ermitteln. 

Miinchener  medicinische  Wochenschrift,  1900,  No.  29. 
Morris,  M. — Finsen's  Light  and  X-Rays  in  Treatment  of  Skin  Diseases. 

Lancet,  1901,  ii,  p.  405. 
Morton,  W.  J.— The  X-Ray.    1896. 

—  The  Probabilities  of  the  Action  of  X-Rays  in  Cancer.    Medical  Rec- 

ord, 1901,  lx,  p.  943. 

—  Radiotherapy  for  Cancer  and  Other  Diseases.     Medical  Record,  May 

24,  1902,  p.  801. 

—  The  Treatment  of  Malignant  Growths  by  the  X-Ray,  with  a   Pro- 

visional   Report   on    Cases    under    Treatment.      Medical    Record, 
March  8,  1902. 

—  Recent  Advances  in  Electrotherapeutics.     Medical  Xews,  December 

27,  1902. 

—  Some  Cases  Treated  by  the  X-Rays.     Medical  Record,  May  30,  July 

25,  and  August  8,  1903. 

Mosetig-Moorhof,     von — Knochenplomben,     K.     K.     Gesellschaft     der 

Aerztein  Wien,  12.     December,  1902. 
Xaunyn — Durchgangigheit     der     Gallensteine     fiir     Rontgenstrahlen, 

Miinch.  med.  Wochenschrift,  August   14,  1900. 
Oberst — Archiv  und  Atlas  der  normalen  und  pathologischen  Anatomie 

in   typischen   Rontgenbildern,   erster  Theil — Die   Fracturen   und 

Luxationen.     Hamburg,  190.     Lucas  Grafe  und  Sillem. 
Oilier — Demonstration  par  les   rayons  de  Rontgen  de  la  regeneration 

osseuse   chez   l'homme   a   la  suite    des   operations   chirurgicales. 

Comptes  Rendus,  17,  v,  1897. 
Oudin  et  Beclere — Pratique  de  la  radiotherapie.    Presse  Med.,  1902. 
Pels-Leuden — Exostosis    cartilaginea    multiplex,    Freie    Verg.    d.    Chi- 

rurgen  Berlins,  14,  I.,   1901. 
Peraire — Trois  cas  de  corps  etrangers  de  la  main,  deceles  par  la  photo- 

graphie  au  moyen  des  rayons  de  Rontgen.     Bulletin  de  la  Societe 

anatomique  de  Paris,  July,  1896. 
Port — Die  Verwendbarkeit  der  Rontgenphotographie  in  der  Zahnheil- 

kunde.   Versammlung  deutscher  Naturforscher  in  Miinchen,  1900. 
30 


450  THE    EONTGEN    RAYS 

Pratt — The  Value  of  the  X-Ray  from  a  Diagnostic  and  Therapeutic 
Standpoint.     The  American  X-Bay  Journal,  Vol.  4,  1899,  No.  4. 

—  X-Eays  as  a  Therapeutic  Factor.    American  X-Eay  Journal,  October, 

1901. 
Pusey — Cases    of    Sarcoma    and    Hodgkin's    Disease    Treated    by    Ex- 
posure to  the  X-Rays.    Journal  of  the  American  Medical  Associa- 
tion, January  18,  1902. 

—  The  Eontgen  Eays  in  the  Treatment  of  Skin  Diseases  and  for  the 

Eemoval  of  Hair.    Chicago  Medical  Eecorder,  April,  1900,  p.  279. 

—  The  Eontgen  Eays  in  the  Treatment  of  Diseases  of  the  Skin.    Trans- 

actions of  the  American  Dermatological  Association,  1901,  p.  184. 
Eontgen — Eine  neue  Art  von  Strahlen,  I.  Mittheilung,  Sitzungsberichte 
der  phys.  med.     Gesellschaft  zu  Wiirzburg,  November,  1895. 

—  Eine  neue  Art  von   Strahlen,  II.   Mittheilung,  Sitzungsberichte  der 

phys.  med.     Gesellschaft  zu  Wiirzburg,  April,  1896. 

—  Ueber    eine    neue    Art    von     Strahlen.      Physikalisch-medicinische 

Gesellschaft  zu  Wiirzburg,  January,  1897. 

—  Weitere    Beobachtungen    iiber    die    Eigenschaften    der    X    strahlen. 

Akademie  der  Wissenschaften,  Berlin,  May  12,  1897,  p.  576. 

—  Weitere  Beobachtungen,  3.  Mittheilung,  Wiedemann's  Annalen,  Bd. 

64,  p.  18. 

Rieder,  H. — Nochmals  die  Bakterientoedtende  Wirkung  der  Eontgen- 
strahlen.     Miinchener  med.  Wochenschrift,  1902,  xlix,  p.  402. 

Eobarts,  Heber — Hypertrichosis.  American  Journal  of  Dermatology 
and  Genito-urinary  Diseases,  1902,  Heft  6. 

Eollins,  W.  H. — X-Light  Kills.  Boston  Medical  and  Surgical  Journal, 
F'ebruary  14,   1901. 

Rumpf — Ueber  die  Bedeutung  der  Eontgenbilder  fiir  die  innere  Medi- 
cin,  Versammlung  deutscher  Naturforscher  und  Aerzte.  Braun- 
schweig, September  21,  1897. 

—  Ehino-  und  Laryngologie.     Archiv  fiir  Laryngologie,  197. 
Schaudinn — Influence    des    rayons    de    Rontgen    sur    les    protozoaires. 

Arch,   d'electrieite  med..  No.  SO,   1900. 
Schede — Die  angeborene  Luxation  des  Hueftgelenkes.    Hamburg,  Lucas 

Griife  und  Sillem,  1900. 
Schiff — Ueber   die   Einfiihrung   der   Eontgenstrahlen   in   die   Dermato- 

therapie.     Archiv  fiir  Dermatologie  und  Syphilis,  189S,  Heft  i. 

—  Der   gegenwaertige    Stand   der   Eontgentherapie,    Eeferat,   erstattet 

auf  dem  vii.  Dermatologencongress  in  Breslau,  1900. 

—  Der    gegenwaertige    Stand    der    Eadiotherapie.      Wiener    klinische 

Wochenschrift,  1900,  No.  37,  p.  827. 

Schjerning — Die  Schnssverletzungen.  Hamburg,  Lucas  Griife  und  Sil- 
lem, 1902. 

Schjerning-Kranzfelder,  Berlin — Ueber  die  von  der  Medicinalabthei- 
rung  des  Kriegsministeriums  angestellten  Versuche  zur  Fests- 
tellung  der  Verwertbarkeitung  Eontgen'  scher  Strahlen  fiir  medi- 
cinisch-chirurgische  Zwecke.  Deutsche  med.  Wochenschrift,  1898, 
Heft  4,  p.  211. 


BIBLIOGRAPHY  451 

Scholz — Qeber  die  Wirkung  der  Rontgenstrahlen  auf  die  Haul.  Allge- 
meine  medicinische  Centralzeitung,  1901,  No.  4.".. 

Schott — Experimente  mit  Rontgenstrahlen  iiber  acute  Herzueberan- 
strengung.  Deutsche  medicinische  Wochenschrift,  L897,  No.  31, 
p.  495. 

Schiirmayer — Die  elektrischen  Lichtererscheinugen.  Allgemeine  medi- 
cinische Centralzeitung,  Berlin,  1898. 

—  Die  letzten   Neuerungen   auf  dem    Rontgengebicte,   Miinchen,   Seitz 

und  Schauer,  1901. 
Senn — Medico-surgical  Aspects  of  the  Spanish-American   War.     Amer- 
ican Medical  Association    Press,  Chicag'O,   1900. 

—  Hodgkin's      Disease.       New      York      .Medical      Journal,      April      18, 

1 903. 

Sequeira,  J.  11. — The  X-Ray  Treatment  in  Diseases  of  the  Skin.  British 
Medical  Journal,  1901,  ii,  p.  850. 

Sick,  C. — Die  Entwickelung  der  Knochen  der  unteren  Extremitat, 
dargestellt  in  Rontgenbildern.  Hamburg,  Lucas  Griife  und  Sil- 
lem,  1902. 

Skinner,  Clarence  E. — X-Light  in  Therapeutics.  Medical  Record,  De- 
cember 27,  1902. 

Sokolow — Rheumatism.     Wratsch,  1S97,  No.  40. 

Stechow — Fussoedem  und  Rontgenstrahlen.  Deutsche  Militaeraerzt- 
lische  Zeitschrift,  1897,  Nr.  11. 

Steinthal — Die  isolirte  Fractur  der  Eminentia  eapitata  im  Ellenbogen- 
gelenk.  Centralblatt  fiir  Chirurgie.  Deutsche  Militaeraerztliehe 
Zeitschrift,  1S97. 

Stenbeck — Rodent  Ulcers  Healed  by  X-Rays.  British  Medical  Journal, 
1901,  i,  epitome,  p.  36. 

Straeter — Welche  Rolle  spielen  die  Roehren  bei  der  therapeutischen 
Anwendung  der  Rontgenstrahlen?  Deutsche  medicinische  Woch- 
enschrift, 1900,  No.  34. 

Sudeck — Ueber  Knochenatrophie.  31.  Versammlung  der  Deutscher 
Gesellschaft  fiir  Chirurgie,  April  2d-5th,  1902. 

Swain — Renal  Calculi.     Lancet,  December,  1897. 

Sweet,  William  M. — The  Treatment  of  Epithelioma  of  the  Eyelids  by 
the  X-Rays.     American  Medicine,  December  13,  1902,  p.  935. 

Tarkhanoff — Raggi  di  Rontgen.     Gaz.  degli  osped,  March  4,  1897. 

Taylor — Congenital  Absence  of  the  Radius.  Transactions  of  the 
American  Orthopaedic  Association,  1897,  p.  170. 

Thompson — The  Uses  of  the  Rontgen  Rays  in  Surgery.  American 
Practitioner  and  News,  xxi,  5,  1896. 

Thompson,  Edward  P. — Rontgen  Rays  and  Phenomena  of  the  Anode 
and  -Cathode.     New  York,  D.  Van  Nostrand  Company,  1899. 

Tilman — Luxation  der  Handwurzelknochen,  Deutsche  Zeitschrift  fiir 
Chirurgie,  1898,  Bd.  49,  p.  98. 

Tonta — Raggi  di  Rontgen.     Milano,  1898. 

Tuffier  et  Loubet — Traitement  des  fractures.  Congres  Beige  de  Chirur- 
gie, Sept.  9,  1902. 


452  THE    RONTGEN    RAYS 

Turner — A  Manual  of  Practical  Medical  Electricity,  etc.  New  York, 
William  Wood  &  Co.,  1902. 

Tuttle — On  X-Eay  Burns.     Medical  Record,  April  4,  1903,  p.  554. 

Unna — Zur  Kenntniss  der  Hautveraenderungen  nach  Durehleuchtung 
mit  Rontgenstrahlen.  Deutsche  Medicinalzeitung,  1898,  No.  20, 
p.  197. 

Villard — Ueber  Reflexion  und  Brechung  der  Kathodenstrahlen.  Comp- 
tes  Rendus,  1900,  No.  130. 

Vulpius — Demonstrationen  von  Aktinogrammen  von  Klumpfuessen. 
Versammlung  deutscher  Naturf'orscher  und  Aerzte  in  Braun- 
schweig, September,  1897. 

Walker,  Norman — X-Ray  Treatment  of  Diseases  of  the  Skin.  British 
Medical  Journal,  1901,  ii,  p.  852. 

Walsh — Deep-tissiie  Traumatism  from  Rontgen-Ray  Exposure.  Brit- 
ish Medical  Journal,  1897,  p.  1095. 

Walter — Physikalisch-technische  Mittheilungen.  Fortschritte  auf  dem 
Gebiete  der  Rontgenstrahlen,  Heft  15,  1897  and  1898. 

—  Ueber  Bequerelstrahlcn.    Fortschritte  auf  dem  Gebiete  der  Rontgen- 

strahlen, Bd.  iii,  Heft  2. 

Weinberger — Zum  radiographlschen  Verhalten  pathologischer  Pro- 
cesse  der  Brustaorta.  Wiener  klinische  Wochenschrift,  1900. 
No.  28. 

— -Atlas  der  Radiographic  der  Brustorgane.  Engel,  Wien  und  Leipzig, 
1902. 

Wenhardt,  J — A  gyogykeserletek  a  Rontgenengarrakal  es  azok  nemely 
atasairal  Ujabb.  gyogyszer.  es  gyogymod.     Budapest,  1S97,  p.  9. 

Wharton — Epithelioma  of  the  Orbit;  Treatment  by  X-Rays.  Annals 
of  Surgery,  1902,  xxxvi,  p.  452. 

White,  Goodspeed,  and  Leonard — Cases  Illustrative  of  the  Practical 
Application  of  the  Rontgen  Raj^s  in  Surgery.  American  Journal 
of  the  Medical  Sciences,  Sc.  cxii,  2,  p.  125,  August,  1896. 

Whitman,  Royal — Further  Observations  on  Fracture  of  the  Neck  of  the 
Femur  in  Childhood,  with  special  reference  to  its  diagnosis  and 
to  its  more  remote  results.  Transactions  of  the  American  Ortho- 
paedic Association,  May,  1897. 

Williams,  Francis  H. — Notes  on  the  Treatment  of  Epidermoid  Cancer. 
Boston  Medical  and  Surgical  Journal,  April  4,  1901,  p.  329. 

—  The  Rontgen  Rays  in  Medicine  and   Surgery.     New  York  and  Lon- 

don, 1902. 

—  The   Rontgen   Rays  in   Thoracic   Affections.     American   Journal   of 

the  Medical  Sciences,  December,  1897. 
Wilms — Verwertung  der  Rontgographie  zum  Studium  der  Geschwuelste. 

Beitriige  zur  Geburtshilfe  und  Gynaekologie,  iii. 
Wilms   und   Sick — Die   Entwickelung  der  Knochen   der   Extremitaeten 

von    der    Geburt    bis    zum    vollendeten    Wachsthum.      Hamburg, 

Lucas  Griife  und  Sillem,  1902. 
Wolfenden,  von,  and  Forbes  Ross — The  Effects  Produced  in  Cultures  of 

Microorganisms  and  of  Tubercle  Bacilli  by  Exposure  to  the  In- 


BIBLIOGEAPHY  453 

fluence  of  an  X-Ray  Tube.    Archives  of  the  Rontgen  Kay,  August, 

1900,  p.  4. 
Wood,  N. — Depilation  by  Rontgen  Rays.     Lancet,  1900,  i.  |>.  231. 
Woods,   R.  F. — A   Case  of  Lupus   Erythematosus  Cured   by  the   X-Ray. 

American  Journal  of  the  Medical  Sciences,  1901,  exxii,  p.  834. 
Zeit,  F.  R. — Effect  of  Direct  Alternating  Tesla  Currents  and  X-Rays  on 

Bacteria.    Journal    of    the    American    Medical    Association,    1901, 

xxxvii,  p.  1432. 
Ziemssen    und    Rieder — Die    Rontgographic    in    der    inneren    Medicin, 

Wiesbaden,  1901. 


INDEX 


Abdomen,  109. 

Acetabular  margin,  fracture  of,  147. 

Acne,  385. 

Acromegaly,  267. 

Actinium,  435. 

Adenoma,  treatment  by  the  Rontgen 

rays  in,  429. 
Air-brake  wheel,  16. 
Albers-Schonberg's   compression    dia- 
phragm, 35. 
Alopecia  areata,  384. 
Amoeba  princeps  (Ehrbg.),  367. 
Aneurysm,  causing  osseous  atrophy, 
105. 

femoral,  150. 

popliteal,  152. 
Ankle-joint,  162. 
Ankylosis  of  knee,  159. 

of  shoulder.  185. 
Aorta,  aneurysm  of,  101. 
Apparatus,  electric,  7. 
Arteriosclerosis,  95. 
Arthritis,  275. 
Arthritis  deformans,  278. 
Arthritis  deformans  coxa?,  147. 
Arthritis  gonorrhoica,  276. 
Astragalus,  169. 
Atrophy,  acute  inflammatory,  260. 

of  shoulder-joint,  261. 

Bacillus  coli  communis,  367. 
Bacillus  prodigiosus,  366. 
Backward  dislocation  of  elbow,  202. 
Bactericidal    properties    of    Rontgen 

rays,  365. 
Barium  platino-cyanide,  2. 
Beck's  movable  diaphragm,  38. 
osteoscope,  26. 


Becquerel  rays.  431. 

Benoist's  radiochromometer,  377. 

photometric  scale,  25. 
Blepharitis,  384. 
Brachydactylism,  243. 
Bullets  in  skull,  71. 
Burns,  legal  aspect  of,  355. 

difference    between    ordinary    and 
such  cured  by  Rontgen  rays.  365. 
Burow's  solution  in  dermatitis,  376. 

Calcaneum,  169. 
Calculi,  biliary,  111. 

intrahepatic,  117. 

renal,  127. 

ureteral,  127. 

vesica],  128. 
Caldwell  interrupter,  14. 
Carcinoma,  metamorphosis  shown  by 

the  microscope,  392. 
Carcinoma,  therapy  of,  390. 
Cathode  ray,  1. 

Chemical  action  of  Rontgen  rays,  361. 
Chest,  85. 
Cholelithiasis,  111. 
Chondroma,  297. 

Chromoradiometer  of  Holzknecht, 25. 
Chronic  Rontgen-light  dermatitis.  369. 
Clavicle,  179. 

Club  hand,  congenital,  247. 
Coley's  experience  in  the  treatment  of 

carcinoma,  419. 
Colloid  degeneration  in  carcinomaafter 

irradiation,  392. 
Condyle,  external,  of  the  humerus,  195. 
Convolvulus  arvensis,  367. 
Coronoid  process  of  ulna,  204, 208, 277. 
Cosmetic  considerations,  377. 
455 


456 


INDEX 


Crookes,  1. 
Crookes'  tube,  1. 

Cuneiform  osteotomy  in  deformed  frac- 
tures, 316. 
Current,  sources  of,  8. 
Cyst,  osseous,  298. 

Dactylitis  syphilitica,  283. 
Dark  room,  46. 

lantern,  46. 
Density  of  objects,  61. 

organic  tissues,  62. 
Dentistry,  value  of  Rontgen  rays  in, 

74.  " 
Depilation,  382. 
Dermatitis,  368. 
Developers,  46. 

Developing  photographic  plates,  44. 
Diaphragms,  33. 
Disintegration   of   tissue  in  excessive 

burns,  364. 
Dislocation  of  shoulder,  186. 

habitual,  of  shoulder,  188. 
Distance  of  tube,  59. 

of  tube  in  therapy,  378. 
Donath's  measuring  stand,  43. 
Drop  wrist,  201. 

Ear,  rudimentary,  65,  246. 
Eczema,  385. 
Elbow-joint,  193. 

in  children,  194. 
Elephantiasis,  386. 
Embryo,  development  of,  139. 
Enophthalmus,  69. 
Epiphyseal  separation  at  lower  end  of 

radius,  229. 
Epithelioma,  392,  397. 
Errors  in  skiagraphy,  351. 
Examination  of  patient,  58. 
Exophthalmus   caused  by   tuberculo- 
sis, 268. 
Exostoses,  295. 
Exposure,  length  of,  378. 

repetition  of,  378. 
Extracapsular  fracture  of  neck  of  fe- 
mur, 147. 
Extremity,  lower,  147. 

upper,  178. 
Eyeball,  foreign  bodies  in,  68. 


Facial  bones,  65. 

fractures  of,  69. 
Favus,  383. 
Femur,  147. 

congenital  shortening  of,  248. 
Fibrosarcoma,  417. 
Field-apparatus,  9. 
Finsen  method,  436. 
Fluoroscopy,  39. 

Flute-mouth  fracture  of  tibia,  163,  351. 
Foetus,  see  embryo. 
Forearm,  209. 
Foreign  bodies,  53. 

extraction  of,  69. 

in  eyeball,  68. 

in  the  abdomen,  131. 

in  the  knee,  160. 
Fractures,  deformed,  310. 

early  treatment  of,  by  osteotomy,  318. 

utilization  of  Rontgen  rays  in,  306. 
Frontal  sinus,  72. 

Fragments,  removal  of  fractured,  326, 
330. 

Geissler,  1. 

Glioma,  413. 

Gorl  lamp,  436. 

Goitre,  Rontgen  method  in,  82. 

Grunmach  tube,  21. 

Gundelach's  hydrogen  arrangement, 
18. 

Gunshot  wound  of  tibia  (experimen- 
tal), 338. 

Gynecology,  value  of  the  Rontgen 
method  in,  137. 

Hair  in  dermatitis,  374. 
Hand,  233. 

congenital  dislocation  of,  247. 
Hard  tubes,  27. 
Head,  63. 
Heart,  93. 
Hertz,  2. 

Hildebrand's  apparatus,  50. 
Hip,  congenital  dislocation  of,  142. 

inflammation  in,  145. 
Hittorf,  1. 

Hirschmann's  orthodiagraphic  appa- 
ratus, 43. 

tube,  18. 


INDEX 


457 


Hodgkin's  disease,  425. 
Holzknecht's  ehroraoradiometer,  377. 
Humerus,  fracture  of  anatomical  neck, 
183. 
fracture  of  shaft,  191. 
fracture  of  surgical  neck,  181. 
osteomyelitis  in,  190,  250. 
wiring   of,  to   the  acromion   in    old 
dislocation,  187. 
Hydrogen  diffusion  in  tube,  18. 
Hydromeningocele,  65. 
Hydropneumothorax,  92. 
Hyoid  bone,  fracture  of,  81. 
Hyperemia   caused   by   the    Rontgen 
rays,  361. 
importance  of,  in  tuberculosis.  366. 
387. 
Hypertrichosis,  381. 

Idiosyncrasy,  371,  377. 

Indentation  of  fragments  in  osteotomy, 
313. 

Indistinct  skiagraphs,  348. 

Induction-coil,  10. 

Inferior  maxilla,  fracture  of,  71. 
growths  of  the,  73. 

Injuries,  legal  questions  in,  345. 

Intensifying  image.  48. 

Internal  malleolus,  fracture  of,  166. 

Interrupters,  13. 

Intracapsular  fracture  of  neck  of  fe- 
mur, 147. 

Introduction,  1. 

Iodoform,  injection  of,  in  goitre,  83. 

Juxtaposition    of    fragments    in    de- 
formed fractures,  328. 

Kidneys,  121. 

Klebs-Loefner  bacillus,  367. 
Knee-joint,  154. 

tuberculosis  of,  265. 
Kny  tube,  18. 
Kuemmel's  stereoscopic  apparatus,  50. 

Labyrinthula  dacryocystis  Cientk,  367. 
Larynx,  fracture  of,  81. 
Lead  mask    in    Rontgen    light  treat- 
ment, 381. 


Leg.  160. 
Lenard,  1. 

Lepidium  sativum,  367. 
Levi  tube,  18. 

Levy-Doras    orthodiagraphy   appara- 
tus, 43. 
Lime  salts,  density  of.  61. 
Lipoma  of  thigh,  293. 
Liver,  110. 
Lungs,  abscess  of.  88. 

echinococcus  of,  88. 

gangrene  of.  88. 
Lupus  vulgaris,  386. 

erythematodes,  389. 
Lymphoma,  treatment  by  the  Rontgen 
rays  in,  429. 

Malformations,  241. 
Malingerers,  exposure  of,  341,  344. 
Malleolar  fracture,  163,  167. 
Malunion  in  metatarsal  fracture,  177. 
Measuring  degree  of  vacuum,  24. 
Measuring  stand,  Hoffmann's,  43. 
Mediastinum,  tumor  of,  97. 
Medico-legal  aspects  of  the  Rontgen 

rays,  339. 
Mediocre  skiagraphs,  348,  349. 
Medium   degree  of    vacuum   in   tube, 

29. 
Melanosarcoma,  408. 
Mercury  interrupter,  16. 
Metacarpus,  234. 

splint  for  fracture  of,  236. 
Metastasis  in  carcinoma.  392,  399. 

metatarsus,  172. 

fracture  of,  173. 
Method  of  therapeutic  irradiation,  376, 
380. 

of  therapeutic  irradiation  in  malig- 
nant disease,  395. 
Mice,  experiments  on,  363. 

effects  of  radium  on,  433. 
Microscopical  examination  in  Rontgen- 

light  dermatitis,  363,  373. 
Moritz's    orthodiagraphic    apparatus, 

43. 
Morton's  principle,  439. 
Muller  tube,  18. 
Multiple  fractures,  legal  aspect  of,  355 


458 


INDEX 


Myelosarcoma,  287. 
Myxcedema,  297. 

Naevus  vasculosus  (flammeus),  386. 
Nasal  bones,  congenital  absence  of,  246. 

bones,  diastasis  of,  67. 
Nature  and  properties  of  the  Rontgen 

rays,  1. 
Neck,  78. 

foreign  bodies  in,  78. 
Necrosis,  254. 

of  radius,  258. 
Needle  in  foot,  341. 

in  hand,  340. 
Negative  pole,  1. 
Neoplasms,  284. 
Nephrolithiasis,  123. 
Nerves,  interposition  of,  in  fractures, 

317. 
Neuralgia,  caused  by  dental  roots,  77. 

treatment  by  the  Rontgen  rays  in, 
429. 
Noma,  430. 
Non-union  of  fractures,  329. 


Obstetrics,  value  of  Rontgen   method 

in,  138. 
(Esophagus,  foreign  bodies  in,  79. 

stenosis  of,  99. 
Olecranon,  wiring  in  fracture  of,  324. 
Orbit,  sarcoma  of,  65. 
Orthodiagraphy,  43. 
Osmo-regeneration,  18. 
Osseous  cysts,  298. 
Osteoarthropathie        hypertrophiante 

pnenmatique,  297. 
Osteoma,  294. 

of  finger,  295. 
Osteomalacia,  275. 
Osteomyelitis,  249. 
Osteoperiostitis,  255. 
Osteoplastic    operation  in   compound 

fracture  of  nlna,  334. 
Osteosarcoma,  284. 

microscopical  examination  of,  415. 

treatment  by  the  Rontgen  rays  in. 
413. 
Osteoscope,  26,  377. 


Osteotomy  in  deformed  fractures,  313. 
Os  trigonum  tarsi,  170. 
Overexposure,  47,  48. 

Patella,  155. 

synostosis  between  femur  and,  270. 

Peculiarities  in  infants,  65. 

Pelvis,  142. 

Pericarditis,  94. 

Periosteal  sarcoma,  285. 

Pirogoff's   operation,  modification  of. 
335. 

Pigmentation  in  dermatitis,  380. 

Pitschblende.  431. 

Phlebolith,  152. 

Phonation,  physiology  of,  64. 

Pleura,  91. 

Plenritis,  91. 

Polonium,  431. 

Polydactylism,  241. 

Popliteal  space,  158. 

Portable  apparatus,  8. 

Position   of  patient  during  examina- 
tion, 59. 

Positive  pole,  1. 

Postero-medial   dislocation    of  elbow, 
203. 

Pott's  fracture,  165. 

fracture,  Beck's  mode  of  reduction 
and  immobilization,  164. 

Predisposition  to  Rontgen  light  derma- 
titis, 376. 

Prints,  photographic,  49. 

Psoriasis,  385. 

Puerperal  sepsis  causing  arthritis  and 
tenonitis,  257. 

Pyothorax,  91. 

Queen's  examining  table,  58. 

Radium,  431. 

Radius,  alleged  reduction  of  fracture 
of,  216. 

fissure  of  head  of,  206,  347. 

forward  dislocation  of,  204. 

fracture  of  head  of,  205. 

fracture  of  lower  end  of,  218. 
Raynaud's  disease,  297. 
Recurrence  in  carcinoma,  391,  401. 


INDEX 


459 


Regeneration  oi'  Lubes,  18. 

Rhachitis,  273. 

Rhaehitic  pelvis,  136. 

Rheostat,  1C. 

Rheumatism,  treatment  of,  427. 

Rhinology,  value  of  Rontgen  rays  in, 

72. 
Ribs,  fracture  of,  105. 
Rickets,  see  rhachitis. 
Rontgen,  2. 
Rontgen  tube,  7. 
Rontgography,  see  skiagraphy. 
Rimtgoscopy,  see  fluoroscopy. 

Sarcoma,  284. 

treatment  by  the  Rontgen  rays  in, 
407. 
Scaphoid  bone,  fracture  of,  230. 
Scapula,  fracture  of,  105. 
Screen,  fluorescing.  39. 
Sequestrum  in  radius,  254. 

in  femur,  150,  257. 
Sesamoid  of  the  semitendinosus  mus- 
cle, 158. 
Shenton's  method  for  localizing  foreign 

bodies,  54. 
Shoulder,  178. 
Skiagraphy,  44. 
Skiameter,  24. 
Skin,  influence   of   Rontgen  rays  on, 

362. 
Skull,  tuberculous  destruction  of,  270. 
Soft  tubes,  29. 
Special  indications  for  Rontgen  light 

treatment,  381. 
Spina  bifida,  132. 
Splint  for  fracture   of   lower   end   of 

radius,  225. 
Spondylitis,  108. 
Stand  developing,  47. 
Staphylococcus  pyogenes  aureus,  366. 
Static  machine,  11. 
Stereofluoroscopy,  49. 
Stereoskiagraphy,  49. 
Stomach,  tumors  of  the,  132. 
Supernumerary  toes,  247. 
Superior  maxilla,   congenital  absence 
of  nasal  processes  of,  248. 


Supracondylar    fracture   <>f   humerus, 

197. 
Susceptibility,  371. 
Sykosis,  382. 
Syndactylism,  241. 
Syphilis,  280. 

Technique  of  Rontgen  examination,  58. 
Teeth,  development  of,  74. 

films  for  the,  75. 
Teleangiectasis    after    Rontgen    light 

dermatitis,  374. 
Tenonitis  prolifera  calcarea,  26s. 
Tentative  exposures.  377. 
Therapeutic     effects   of    the  Rontgen 

rays,  300. 
Thoracic  organs,  relations  of.  180. 
Thoracic  wall,  tumors  of,  98. 
Thorium,  435. 
Tibia,  fracture  of,  161. 
Tissues,  different  reaction  of.  379. 
Tracing  apparatus,  40. 
Treatment  of  Rontgen  light  dermati- 
tis, 376. 
Trichophytosis,  383. 
Trochanter,  fracture  of,  147. 
Tuberculosis,  264. 

treatment  by  the  Rontgen  rays  in, 
428. 
Tuberculous  foci  in  the  lungs.  88. 
glands  of  neck,  shown  by  the  Ront- 
gen rays,  83. 
Tubes,  17. 

Tungstate  of  calcium  screen,  39. 
Typhoid  bacillus,  367. 
Tumors  of  the  stomach,  132. 

Ulcus  rodens,  392. 
Ulna,  217. 

dislocation    of,  in   association   with 
fracture  of  radius,  232. 

fracture  of.  in  association  with  frac- 
ture of  radius,  231. 
Ultraviolet  rays,  436. 
Underexposure,  47,  48. 
Uranium,  431. 
Urticaria  pigmentosa.  386. 
Usefulness  of  Rontgen  rays,  3, 


4G0 


INDEX 


Vacuum  of  tubes,  22, 
Veins,  ossification  of,  97. 

sclerosis  of,  96. 
Ventile  tube  of  GundeRch,  19. 
Vertebras,  fracture  of,  81. 

fracture  of  dorsal,  107. 
Villard's  ampoule  a  osmo-regulateur. 

377. 
Voltohm  tube,  18. 

Walter  commutation,  11. 
skiameter,  24. 
tube,  21. 


Wehnelt  interrupter,  13,  32. 

Wire-letters,  Beck's,  for   localization, 
53,  55. 

Wiring  of    fragments    in    osteotomy, 
314. 

Wiring  head  of  humerus  to  the  acro- 
mion, 187. 
radius  and  ulna  in  malunion,  214. 

Wrist,  218. 


Xeroform-gauze  in  dermatitis,  376. 
Xeroform-lanolin  in  dermatitis,  376. 


(1) 


THE   END 


